Provider Demographics
NPI:1598494882
Name:SANDROCK, GRANT (CDCA)
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:SANDROCK
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 S CHESTNUT ST STE 302
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-3029
Mailing Address - Country:US
Mailing Address - Phone:330-297-7842
Mailing Address - Fax:
Practice Address - Street 1:143 GOUGLER AVE
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44240-2401
Practice Address - Country:US
Practice Address - Phone:330-677-4124
Practice Address - Fax:330-677-4134
Is Sole Proprietor?:No
Enumeration Date:2022-06-10
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0002282175T00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist