Provider Demographics
NPI:1548836372
Name:GRANT, GWENDOLYN
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 OVERLOOK AVE APT 14D
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-2223
Mailing Address - Country:US
Mailing Address - Phone:646-880-7869
Mailing Address - Fax:
Practice Address - Street 1:1434 110TH ST STE 303
Practice Address - Street 2:
Practice Address - City:COLLEGE POINT
Practice Address - State:NY
Practice Address - Zip Code:11356-1448
Practice Address - Country:US
Practice Address - Phone:718-569-5439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-02
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician