Provider Demographics
NPI:1962392670
Name:GRANT, TAREZE
Entity type:Individual
Prefix:
First Name:TAREZE
Middle Name:
Last Name:GRANT
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1776 BUNK NEWELL RD
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-8432
Mailing Address - Country:US
Mailing Address - Phone:601-934-0592
Mailing Address - Fax:
Practice Address - Street 1:4400 OLD CANTON RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-5982
Practice Address - Country:US
Practice Address - Phone:601-984-5236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-04
Last Update Date:2025-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health