1700808961 NPI number — MS. MARY ELIZABETH GRANT LPC

Table of content: MS. MARY ELIZABETH GRANT LPC (NPI 1700808961)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700808961 NPI number — MS. MARY ELIZABETH GRANT LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRANT
Provider First Name:
MARY
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WILLIAMS-WILKERSON
Provider Other First Name:
MARY
Provider Other Middle Name:
ELIZABETH
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1700808961
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
871 RIDGEWAY LOOP ROAD
Provider Second Line Business Mailing Address:
SUITE 108
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38120
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-871-0170
Provider Business Mailing Address Fax Number:
901-871-0353

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
871 RIDGEWAY LOOP ROAD
Provider Second Line Business Practice Location Address:
SUITE 108
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-871-0170
Provider Business Practice Location Address Fax Number:
901-871-0353
Provider Enumeration Date:
07/24/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  3350 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YM0800X , with the licence number: MSLPC0311 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)