Provider Demographics
NPI:1003462235
Name:GRANT, GENEVIEVE M
Entity Type:Individual
Prefix:
First Name:GENEVIEVE
Middle Name:M
Last Name:GRANT
Suffix:
Gender:F
Credentials:
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 639561
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-9561
Mailing Address - Country:US
Mailing Address - Phone:847-807-3917
Mailing Address - Fax:847-348-3706
Practice Address - Street 1:2460 W 26TH AVE STE 217
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80211-5308
Practice Address - Country:US
Practice Address - Phone:303-322-7108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-13
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
376K00000X
CORBT-20-137743106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No376K00000XNursing Service Related ProvidersNurse's Aide