Provider Demographics
NPI:1922344860
Name:GRANT, CAROLINE COULLETTE (SAS)
Entity Type:Individual
Prefix:MRS
First Name:CAROLINE
Middle Name:COULLETTE
Last Name:GRANT
Suffix:
Gender:F
Credentials:SAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 N CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:MANNING
Mailing Address - State:SC
Mailing Address - Zip Code:29102-3502
Mailing Address - Country:US
Mailing Address - Phone:803-435-2121
Mailing Address - Fax:
Practice Address - Street 1:14 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:MANNING
Practice Address - State:SC
Practice Address - Zip Code:29102-3502
Practice Address - Country:US
Practice Address - Phone:803-435-2121
Practice Address - Fax:803-435-8856
Is Sole Proprietor?:No
Enumeration Date:2012-12-21
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1730176934Medicaid