Healthcare Provider Details

I. General information

NPI: 1265912232
Provider Name (Legal Business Name): KADIJAH RAGINE GRANT LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2018
Last Update Date: 11/26/2024
Certification Date: 11/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13815 PROFESSIONAL CENTER DR STE 100
HUNTERSVILLE NC
28078-7951
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 704-384-1320
  • Fax: 704-316-3138
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC012626
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP011582
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: