Provider Demographics
NPI:1497312276
Name:THOMPSON-GRANT, STACY-ANN (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:STACY-ANN
Middle Name:
Last Name:THOMPSON-GRANT
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 1:311 HORACE ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06610-1950
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:170 BENNET T STREET
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06605
Practice Address - Country:US
Practice Address - Phone:475-241-4509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-28
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4610104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT222562827Medicaid