Provider Demographics
NPI:1114911443
Name:GRANN, IRA (LCSW)
Entity Type:Individual
Prefix:MR
First Name:IRA
Middle Name:
Last Name:GRANN
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 1:9913 MOORINGS DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-7592
Mailing Address - Country:US
Mailing Address - Phone:904-262-2234
Mailing Address - Fax:904-260-9897
Practice Address - Street 1:1542 KINGSLEY AVE
Practice Address - Street 2:SUITE 145
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4586
Practice Address - Country:US
Practice Address - Phone:904-655-5507
Practice Address - Fax:904-260-9897
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW18011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical