Provider Demographics
NPI:1043230378
Name:GRANT, RANDY COONFIELD (LISW-CP)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:COONFIELD
Last Name:GRANT
Suffix:
Gender:F
Credentials:LISW-CP
Other - Prefix:
Other - First Name:RANDY
Other - Middle Name:
Other - Last Name:COONFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT
Mailing Address - Street 2:SUITE 212
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4545
Mailing Address - Country:US
Mailing Address - Phone:864-797-6044
Mailing Address - Fax:864-797-6198
Practice Address - Street 1:701 GROVE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4210
Practice Address - Country:US
Practice Address - Phone:864-455-8431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0035821041C0700X
SC111521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6003044Medicaid
NC6003044Medicaid
NC2878874Medicare ID - Type UnspecifiedPOLK LCSW GRP. #2335660A