Provider Demographics
NPI:1083040703
Name:GRANT, GRACE L
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:L
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 42
Mailing Address - Street 2:
Mailing Address - City:ISLAND FALLS
Mailing Address - State:ME
Mailing Address - Zip Code:04747-0042
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:66 SHERMAN ST
Practice Address - Street 2:
Practice Address - City:ISLAND FALLS
Practice Address - State:ME
Practice Address - Zip Code:04747-4415
Practice Address - Country:US
Practice Address - Phone:207-463-2034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-26
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXL4025101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health