Healthcare Provider Details

I. General information

NPI: 1922880988
Provider Name (Legal Business Name): NICOLE GRANT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2023
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 LAKEWOOD RD
WATERBURY CT
06704-5408
US

IV. Provider business mailing address

212 PULLEN AVE
WATERBURY CT
06708-1261
US

V. Phone/Fax

Practice location:
  • Phone: 888-793-3500
  • Fax:
Mailing address:
  • Phone: 914-255-3132
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number9194
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: