Provider Demographics
NPI:1144787409
Name:GRANT, CORINNE IVY (LCSW)
Entity type:Individual
Prefix:
First Name:CORINNE
Middle Name:IVY
Last Name:GRANT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:803 E 1ST AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84103-3990
Mailing Address - Country:US
Mailing Address - Phone:801-608-5358
Mailing Address - Fax:
Practice Address - Street 1:525 E 100 S FL 5
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-4210
Practice Address - Country:US
Practice Address - Phone:801-585-1212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-22
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT947259335011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical