Healthcare Provider Details

I. General information

NPI: 1497484455
Provider Name (Legal Business Name): GRANT COURTNEY, LICENSED CLINICAL SOCIAL WORKER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2022
Last Update Date: 06/06/2022
Certification Date: 06/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

566 S SAN VICENTE BLVD STE 101
LOS ANGELES CA
90048-4650
US

IV. Provider business mailing address

6230 WILSHIRE BLVD STE 1180
LOS ANGELES CA
90048-5126
US

V. Phone/Fax

Practice location:
  • Phone: 310-571-5809
  • Fax:
Mailing address:
  • Phone: 310-571-5809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MR. GRANT COURTNEY
Title or Position: PRESIDENT/OWNER
Credential: LCSW
Phone: 310-571-5809