Basic Information
| Provider Information | |||||||||
| NPI: | 1861919805 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRANGER | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CSAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3150 GERSHWIN DR | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543114328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203914700 | ||||||||
| FaxNumber: | 9203914731 | ||||||||
| Practice Location | |||||||||
| Address1: | 3150 GERSHWIN DR | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543114328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203914700 | ||||||||
| FaxNumber: | 9203914731 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 15260-135 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.