Provider Demographics
NPI:1710565890
Name:GRANT, TISHA (LMSW)
Entity Type:Individual
Prefix:
First Name:TISHA
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5401 BALTIMORE NATIONAL PIKE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-2102
Mailing Address - Country:US
Mailing Address - Phone:410-869-4618
Mailing Address - Fax:
Practice Address - Street 1:5401 BALTIMORE NATIONAL PIKE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-2102
Practice Address - Country:US
Practice Address - Phone:410-869-4618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-31
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD26150104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker