Provider Demographics
NPI:1902594914
Name:GRANT, DIANE FROMBGEN (MS ED)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:FROMBGEN
Last Name:GRANT
Suffix:
Gender:F
Credentials:MS ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1465 MARIAN AVE
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-5727
Mailing Address - Country:US
Mailing Address - Phone:734-673-4871
Mailing Address - Fax:
Practice Address - Street 1:2345 SOUTH HURON PARKWAY
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-5727
Practice Address - Country:US
Practice Address - Phone:734-474-5700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-27
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401007605101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional