Provider Demographics
NPI:1609233261
Name:GRANT, THARYN (LCSW)
Entity Type:Individual
Prefix:
First Name:THARYN
Middle Name:
Last Name:GRANT
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1462 CLIFTON RD NE STE 235
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30322-1063
Mailing Address - Country:US
Mailing Address - Phone:773-263-8421
Mailing Address - Fax:
Practice Address - Street 1:1017 FAYETTEVILLE RD SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30316-2932
Practice Address - Country:US
Practice Address - Phone:404-324-4190
Practice Address - Fax:404-324-4191
Is Sole Proprietor?:No
Enumeration Date:2016-01-26
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1184811041C0700X
GACSW0053671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical