Provider Demographics
NPI:1790868446
Name:GRANT, AEDAMAR JACINTA (PHD)
Entity type:Individual
Prefix:
First Name:AEDAMAR
Middle Name:JACINTA
Last Name:GRANT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 EVERGREEN LN
Mailing Address - Street 2:
Mailing Address - City:SEWICKLEY
Mailing Address - State:PA
Mailing Address - Zip Code:15143-1060
Mailing Address - Country:US
Mailing Address - Phone:412-749-9050
Mailing Address - Fax:
Practice Address - Street 1:1107 E CARSON ST
Practice Address - Street 2:FLOOR 2
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15203-1153
Practice Address - Country:US
Practice Address - Phone:412-481-4207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS-006396-L103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling