Provider Demographics
NPI:1366864225
Name:GRANT, ERIC (LCSW)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:GRANT
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 1:1635 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06610-2717
Mailing Address - Country:US
Mailing Address - Phone:203-551-7502
Mailing Address - Fax:203-551-7647
Practice Address - Street 1:1635 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06610-2717
Practice Address - Country:US
Practice Address - Phone:203-551-7502
Practice Address - Fax:203-551-7647
Is Sole Proprietor?:No
Enumeration Date:2014-01-13
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT58.0084861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical