Provider Demographics
NPI:1063574994
Name:GRANT, BRIAN WILLIAM (PH D)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:WILLIAM
Last Name:GRANT
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9507 CADBURY CIR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-1000
Mailing Address - Country:US
Mailing Address - Phone:317-590-2727
Mailing Address - Fax:317-669-2096
Practice Address - Street 1:921 E 86TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240-1859
Practice Address - Country:US
Practice Address - Phone:317-590-2727
Practice Address - Fax:317-669-2096
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20090164A103TH0100X
IN35000590A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200456500AMedicaid
258270Medicare PIN