Provider Demographics
NPI:1265988141
Name:GRANT, MARY CATHERINE (NCC/CCMHC/LCMHC/LCAS)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:CATHERINE
Last Name:GRANT
Suffix:
Gender:F
Credentials:NCC/CCMHC/LCMHC/LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 S MARSHALL ST STE 1
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-2843
Mailing Address - Country:US
Mailing Address - Phone:336-276-1278
Mailing Address - Fax:336-276-1516
Practice Address - Street 1:100 S MARSHALL ST STE 1
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-2843
Practice Address - Country:US
Practice Address - Phone:362-761-2783
Practice Address - Fax:336-276-1516
Is Sole Proprietor?:No
Enumeration Date:2016-08-30
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-21990101YA0400X
NC11728101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)