Provider Demographics
NPI:1114523347
Name:NUSSBAUMGRANT, CARRIE DAWN (LMSW)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:DAWN
Last Name:NUSSBAUMGRANT
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 MANOR RD # B
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-2959
Mailing Address - Country:US
Mailing Address - Phone:917-770-0698
Mailing Address - Fax:
Practice Address - Street 1:402 MANOR RD # B
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-2959
Practice Address - Country:US
Practice Address - Phone:917-770-0698
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-11
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY08923401104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker