Provider Demographics
NPI:1538452933
Name:GRANTHAM, TRACY LYNN (LPC)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:GRANTHAM
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4130 FABER PLACE DR
Mailing Address - Street 2:SUITE 115
Mailing Address - City:N CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29405-8501
Mailing Address - Country:US
Mailing Address - Phone:843-747-5327
Mailing Address - Fax:843-747-0698
Practice Address - Street 1:4130 FABER PLACE DR
Practice Address - Street 2:SUITE 115
Practice Address - City:N CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29405-8501
Practice Address - Country:US
Practice Address - Phone:843-747-5327
Practice Address - Fax:843-747-0698
Is Sole Proprietor?:No
Enumeration Date:2011-05-18
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2835101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor