Healthcare Provider Details

I. General information

NPI: 1154800290
Provider Name (Legal Business Name): KERI INNIS-GRANT MSW PENDING
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2018
Last Update Date: 08/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 GROVE STREET STE LL11
WORCESTER MA
01605
US

IV. Provider business mailing address

108 GROVE ST STE LL11
WORCESTER MA
01605-2677
US

V. Phone/Fax

Practice location:
  • Phone: 508-304-7499
  • Fax: 774-420-7255
Mailing address:
  • Phone: 508-304-7499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number193200000X
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: