Provider Demographics
NPI:1013076413
Name:GRANT, MARCIA K (LCSW LMFT)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:K
Last Name:GRANT
Suffix:
Gender:F
Credentials:LCSW LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 E COOK RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-3636
Mailing Address - Country:US
Mailing Address - Phone:260-489-6030
Mailing Address - Fax:260-489-5536
Practice Address - Street 1:415 E COOK RD
Practice Address - Street 2:SUITE 100
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-3636
Practice Address - Country:US
Practice Address - Phone:260-489-6030
Practice Address - Fax:260-489-5536
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34001472A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM400014673Medicare UPIN