Provider Demographics
NPI:1447028501
Name:GRANTHAM, VICKI ANN (MS)
Entity type:Individual
Prefix:MS
First Name:VICKI
Middle Name:ANN
Last Name:GRANTHAM
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10801 PLATTE VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72212-3654
Mailing Address - Country:US
Mailing Address - Phone:501-786-2433
Mailing Address - Fax:501-614-7254
Practice Address - Street 1:6124 NORTHMOOR DR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72204-2504
Practice Address - Country:US
Practice Address - Phone:501-786-2433
Practice Address - Fax:501-614-7254
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-18
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR85-23EI103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities