Provider Demographics
NPI:1942083050
Name:GRANT, TIAISHA-NICOL (MHC)
Entity Type:Individual
Prefix:
First Name:TIAISHA-NICOL
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:MHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 PALMETTO ST APT 3A
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11221-4950
Mailing Address - Country:US
Mailing Address - Phone:347-204-9466
Mailing Address - Fax:
Practice Address - Street 1:108 S FRANKLIN AVE STE 3
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-6105
Practice Address - Country:US
Practice Address - Phone:516-303-9925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty