Provider Demographics
NPI:1548566086
Name:GRANT, SHANE T (LCSW-C)
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:T
Last Name:GRANT
Suffix:
Gender:M
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 W 40TH ST
Mailing Address - Street 2:SUITE 456-B
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21211-2120
Mailing Address - Country:US
Mailing Address - Phone:410-235-9200
Mailing Address - Fax:410-955-5795
Practice Address - Street 1:711 W 40TH ST
Practice Address - Street 2:SUITE 456-B
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21211-2120
Practice Address - Country:US
Practice Address - Phone:410-235-9200
Practice Address - Fax:410-955-5795
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-01
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD139961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD12192922OtherCAQH