Provider Demographics
NPI:1649638735
Name:GRANT, YANIQUE (LCSW)
Entity type:Individual
Prefix:
First Name:YANIQUE
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:YANIQUE
Other - Middle Name:
Other - Last Name:GRANT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:500 ALBANY AVE
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06120-2508
Mailing Address - Country:US
Mailing Address - Phone:917-412-0021
Mailing Address - Fax:
Practice Address - Street 1:500 ALBANY AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06120
Practice Address - Country:US
Practice Address - Phone:860-249-9625
Practice Address - Fax:860-761-0773
Is Sole Proprietor?:No
Enumeration Date:2016-02-03
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT102611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical