Provider Demographics
NPI:1457346363
Name:GRANTHAM, EMILY J (LCSW)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:J
Last Name:GRANTHAM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 CLAY ST
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-2810
Mailing Address - Country:US
Mailing Address - Phone:276-632-7128
Mailing Address - Fax:276-632-0127
Practice Address - Street 1:30 TECHNOLOGY DR
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:VA
Practice Address - Zip Code:24151-3008
Practice Address - Country:US
Practice Address - Phone:276-632-7128
Practice Address - Fax:276-632-0127
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040060221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004945221Medicaid
VACO4131Medicare ID - Type UnspecifiedEMPLOYER GROUP NO
VA004945221Medicaid