Healthcare Provider Details

I. General information

NPI: 1780744698
Provider Name (Legal Business Name): ELIZABETH ANN GRANT CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 07/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 W. 16TH STREET
BEDFORD IN
47421-3510
US

IV. Provider business mailing address

2900 W. 16TH STREET
BEDFORD IN
47421-3510
US

V. Phone/Fax

Practice location:
  • Phone: 812-279-3747
  • Fax: 812-275-1328
Mailing address:
  • Phone: 812-279-3747
  • Fax: 812-275-1328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number70000056
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number70000056A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: