Provider Demographics
NPI:1053509737
Name:HASTY, GRANT R (LCSW)
Entity Type:Individual
Prefix:MR
First Name:GRANT
Middle Name:R
Last Name:HASTY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 DALTON DR
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19702-2059
Mailing Address - Country:US
Mailing Address - Phone:302-275-8577
Mailing Address - Fax:302-454-7274
Practice Address - Street 1:3135 SUMMIT BRIDGE RD
Practice Address - Street 2:
Practice Address - City:BEAR
Practice Address - State:DE
Practice Address - Zip Code:19701-2001
Practice Address - Country:US
Practice Address - Phone:302-464-0515
Practice Address - Fax:302-454-7274
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-09
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEQ100007651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000039721Medicaid
DE166706 YDXJOtherMEDICARE PTAN
DC1000035733Medicaid