Provider Demographics
NPI:1639610595
Name:KIRKWOOD, GRANT CHARLES (CDCA)
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:CHARLES
Last Name:KIRKWOOD
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:158 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:OH
Mailing Address - Zip Code:44003-9318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:158 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:OH
Practice Address - Zip Code:44003-9318
Practice Address - Country:US
Practice Address - Phone:216-353-4723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-13
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH165555101YA0400X
OH106S00000X
OH000120175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer Specialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty