1033274790 NPI number — MRS. LOUISE GRANT LICSW

Table of content: MRS. LOUISE GRANT LICSW (NPI 1033274790)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033274790 NPI number — MRS. LOUISE GRANT LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRANT
Provider First Name:
LOUISE
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033274790
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
796 CHESTNUT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WABAN
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02468-2039
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-232-5737
Provider Business Mailing Address Fax Number:
617-796-0188

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1093 BEACON ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
BROOKLINE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02446-5695
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-232-5737
Provider Business Practice Location Address Fax Number:
617-796-0188
Provider Enumeration Date:
12/23/2006

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: 1041C0700X , with the licence number:  101123 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 795262 . This is a "TUFTS HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: PO1154 . This is a "BLUE CROSS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 352685 . This is a "MAGELLAN HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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