Provider Demographics
NPI:1851109474
Name:GRANDERSON, DRAYKAR
Entity type:Individual
Prefix:
First Name:DRAYKAR
Middle Name:
Last Name:GRANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21412 HAMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23803-2268
Mailing Address - Country:US
Mailing Address - Phone:804-312-1127
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 152
Practice Address - Street 2:
Practice Address - City:PENNINGTON GAP
Practice Address - State:VA
Practice Address - Zip Code:24277-0152
Practice Address - Country:US
Practice Address - Phone:888-322-3492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-28
Last Update Date:2024-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704015860101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health