Basic Information
| Provider Information | |||||||||
| NPI: | 1639622152 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRANT | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | DUPRIEST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 227 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | FESTUS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630281952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6369312700 | ||||||||
| FaxNumber: | 6369315304 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 SAGE MEADOWS CT | ||||||||
| Address2: | |||||||||
| City: | O FALLON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633664189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033255427 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2016 | ||||||||
| LastUpdateDate: | 05/24/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 1041C0700X | 2022004385 | MO | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.