Provider Demographics
NPI:1598424228
Name:GRANT, ANGEL D (CASE MANAGER)
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:D
Last Name:GRANT
Suffix:
Gender:F
Credentials:CASE MANAGER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 E SAHARA AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89104-3009
Mailing Address - Country:US
Mailing Address - Phone:702-334-4515
Mailing Address - Fax:
Practice Address - Street 1:830 E SAHARA AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-3009
Practice Address - Country:US
Practice Address - Phone:702-334-4515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-09
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1104455476Medicaid