Provider Demographics
NPI:1891231999
Name:GRANT, ELIZABETH JANE (MS)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:JANE
Last Name:GRANT
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 W FLORIDA ST
Mailing Address - Street 2:APT 716
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53204-1509
Mailing Address - Country:US
Mailing Address - Phone:847-530-0406
Mailing Address - Fax:
Practice Address - Street 1:1971 WASHINGTON ST
Practice Address - Street 2:SUITE 200
Practice Address - City:GRAFTON
Practice Address - State:WI
Practice Address - Zip Code:53024-2122
Practice Address - Country:US
Practice Address - Phone:262-377-6276
Practice Address - Fax:262-377-6289
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-12
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18021-130101YA0400X
WI3218-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)