Provider Demographics
NPI:1972504728
Name:BOOTH, GRANT EDWARD (MSW, LICSW, ACSW)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:EDWARD
Last Name:BOOTH
Suffix:
Gender:M
Credentials:MSW, LICSW, ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1499 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-2236
Mailing Address - Country:US
Mailing Address - Phone:651-690-1542
Mailing Address - Fax:651-690-1451
Practice Address - Street 1:1499 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-2236
Practice Address - Country:US
Practice Address - Phone:651-690-1542
Practice Address - Fax:651-690-1451
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN108291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical