Provider Demographics
NPI:1184278749
Name:GRANT, STACEY M
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:M
Last Name:GRANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7768 ANDES DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32244
Mailing Address - Country:US
Mailing Address - Phone:904-434-6920
Mailing Address - Fax:
Practice Address - Street 1:4243 SUNBEAM RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-8848
Practice Address - Country:US
Practice Address - Phone:904-443-4692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-31
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
FLMH24087101YM0800X
FL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)