Provider Demographics
NPI:1851662423
Name:GRANT, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
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 1:2160 N ILLINOIS ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-1334
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2160 N ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1334
Practice Address - Country:US
Practice Address - Phone:317-937-3700
Practice Address - Fax:317-937-3710
Is Sole Proprietor?:No
Enumeration Date:2012-01-13
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34006396A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical