Healthcare Provider Details

I. General information

NPI: 1780897157
Provider Name (Legal Business Name): MARCELLE GRANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

532 DON GASPAR AVE
SANTA FE NM
87505-2626
US

IV. Provider business mailing address

1107 CAMINITO ALEGRE
SANTA FE NM
87501-1605
US

V. Phone/Fax

Practice location:
  • Phone: 505-986-3478
  • Fax:
Mailing address:
  • Phone: 505-982-4927
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1319
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: