Provider Demographics
NPI:1952440364
Name:ANDERSON-GRANT, TELIA NICOLE (NON CREDENTIAL)
Entity Type:Individual
Prefix:
First Name:TELIA
Middle Name:NICOLE
Last Name:ANDERSON-GRANT
Suffix:
Gender:F
Credentials:NON CREDENTIAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:847 NE WEBSTER ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-3848
Mailing Address - Country:US
Mailing Address - Phone:503-998-3946
Mailing Address - Fax:
Practice Address - Street 1:12600 SE STARK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1058
Practice Address - Country:US
Practice Address - Phone:503-477-8208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR171M00000X, 374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No171M00000XOther Service ProvidersCase Manager/Care Coordinator