Provider Demographics
NPI:1205080579
Name:GRANT, MARREN EBERLE
Entity type:Individual
Prefix:MS
First Name:MARREN
Middle Name:EBERLE
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 1:2101 HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:GAUTIER
Mailing Address - State:MS
Mailing Address - Zip Code:39553-5340
Mailing Address - Country:US
Mailing Address - Phone:228-497-7900
Mailing Address - Fax:
Practice Address - Street 1:2809 DENNY AVE
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39581-5301
Practice Address - Country:US
Practice Address - Phone:228-809-2212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-12
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT503290435011041C0700X
MSC74691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical