Provider Demographics
NPI:1538286919
Name:GRANT, POLLY WALKER
Entity Type:Individual
Prefix:DR
First Name:POLLY
Middle Name:WALKER
Last Name:GRANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:POLLY
Other - Middle Name:GRANT
Other - Last Name:RILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD, MSW
Mailing Address - Street 1:86 FRESH POND PKWY
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-3334
Mailing Address - Country:US
Mailing Address - Phone:617-491-3042
Mailing Address - Fax:781-485-6119
Practice Address - Street 1:300 OCEAN AVE.
Practice Address - Street 2:
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151
Practice Address - Country:US
Practice Address - Phone:781-485-6111
Practice Address - Fax:781-485-6119
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1001251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA100125OtherLICSW
SC004676OtherLISW-CP