Provider Demographics
NPI:1871558361
Name:MACDONALD, RONALD GRANT JR (LPC, LISAC)
Entity type:Individual
Prefix:MR
First Name:RONALD
Middle Name:GRANT
Last Name:MACDONALD
Suffix:JR
Gender:M
Credentials:LPC, LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 790
Mailing Address - Street 2:
Mailing Address - City:PAGE
Mailing Address - State:AZ
Mailing Address - Zip Code:86040-0790
Mailing Address - Country:US
Mailing Address - Phone:928-645-5113
Mailing Address - Fax:928-645-3254
Practice Address - Street 1:463 S. LAKE POWELL BLVD
Practice Address - Street 2:
Practice Address - City:PAGE
Practice Address - State:AZ
Practice Address - Zip Code:86040-0790
Practice Address - Country:US
Practice Address - Phone:928-645-5113
Practice Address - Fax:928-645-3254
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-0989101YA0400X
AZLPC-10208101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ832859Medicaid