Provider Demographics
NPI:1073341624
Name:SLADE, GRIFFIN BRANDT (LSUDC)
Entity type:Individual
Prefix:
First Name:GRIFFIN
Middle Name:BRANDT
Last Name:SLADE
Suffix:
Gender:M
Credentials:LSUDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1054 WESLEY POWELL DR # 1
Mailing Address - Street 2:
Mailing Address - City:SAINT GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-7843
Mailing Address - Country:US
Mailing Address - Phone:435-236-9522
Mailing Address - Fax:
Practice Address - Street 1:1085 S BLUFF ST
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-5245
Practice Address - Country:US
Practice Address - Phone:435-674-9999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-24
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12433636-6006101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)