Provider Demographics
NPI:1669834362
Name:GRANT, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 42ND ST
Mailing Address - Street 2:APT 4
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4094
Mailing Address - Country:US
Mailing Address - Phone:570-977-0646
Mailing Address - Fax:
Practice Address - Street 1:415 S 42ND ST
Practice Address - Street 2:APT 4
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4094
Practice Address - Country:US
Practice Address - Phone:570-977-0646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-22
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC012558252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency