Provider Demographics
NPI:1083387526
Name:GRANT, JUSTIN (BSW)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:GRANT
Suffix:
Gender:M
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3535 LEE RD
Mailing Address - Street 2:
Mailing Address - City:SHAKER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44120-5122
Mailing Address - Country:US
Mailing Address - Phone:216-417-4166
Mailing Address - Fax:
Practice Address - Street 1:3535 LEE RD
Practice Address - Street 2:
Practice Address - City:SHAKER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44120-5122
Practice Address - Country:US
Practice Address - Phone:216-417-4166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-30
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty