Healthcare Provider Details

I. General information

NPI: 1245069459
Provider Name (Legal Business Name): NICOLE A GRANT LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2024
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 1ST ST NW
CHOTEAU MT
59422-9378
US

IV. Provider business mailing address

17 1ST ST NW
CHOTEAU MT
59422-9378
US

V. Phone/Fax

Practice location:
  • Phone: 781-854-2861
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number230631
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSC61604804
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberBBH-LCSW-LIC-90269
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: