Provider Demographics
NPI:1538288212
Name:GRANT, KATIE L (MS, LCPC, LMHC, LPC)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:L
Last Name:GRANT
Suffix:
Gender:F
Credentials:MS, LCPC, LMHC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 55TH ST UPPR
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53140-3665
Mailing Address - Country:US
Mailing Address - Phone:563-676-6136
Mailing Address - Fax:855-965-2636
Practice Address - Street 1:1207 55TH ST UPPR
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-3665
Practice Address - Country:US
Practice Address - Phone:563-676-6136
Practice Address - Fax:855-965-2636
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.007951101Y00000X, 101YP2500X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1538288212Medicaid
IL$$$$$$$$$001Medicaid