Provider Demographics
NPI:1578634366
Name:GRANT, CINDY LANE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:CINDY
Middle Name:LANE
Last Name:GRANT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 E OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-3507
Mailing Address - Country:US
Mailing Address - Phone:516-897-3666
Mailing Address - Fax:516-897-3666
Practice Address - Street 1:22 E OLIVE ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561-3507
Practice Address - Country:US
Practice Address - Phone:516-897-3666
Practice Address - Fax:516-897-3666
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR039731101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYND4451Medicare PIN