Provider Demographics
NPI:1679273528
Name:GRANT, MOYA (NCC, LAPC)
Entity type:Individual
Prefix:
First Name:MOYA
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:NCC, LAPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3675 MARKETPLACE BLVD # 1173
Mailing Address - Street 2:
Mailing Address - City:EAST POINT
Mailing Address - State:GA
Mailing Address - Zip Code:30344-5730
Mailing Address - Country:US
Mailing Address - Phone:678-487-9763
Mailing Address - Fax:
Practice Address - Street 1:11201 JEFFERSON CIR N
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30341-2690
Practice Address - Country:US
Practice Address - Phone:678-487-9763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-08
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC014371101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health