Provider Demographics
NPI:1841203338
Name:GRANT, CORINE DODGE
Entity Type:Individual
Prefix:
First Name:CORINE
Middle Name:DODGE
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 1:609 BIRKDALE CIR W
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-4303
Mailing Address - Country:US
Mailing Address - Phone:850-897-6911
Mailing Address - Fax:850-729-5022
Practice Address - Street 1:1813 JOHN SIMS PKWY E
Practice Address - Street 2:SUITE 1
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-2337
Practice Address - Country:US
Practice Address - Phone:850-729-5009
Practice Address - Fax:850-729-5022
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4826101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health