Healthcare Provider Details

I. General information

NPI: 1679332407
Provider Name (Legal Business Name): MARVA L GRANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2024
Last Update Date: 03/18/2026
Certification Date: 03/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3445 S MAIN ST
COVENTRY TOWNSHIP OH
44319-3028
US

IV. Provider business mailing address

3445 S MAIN ST
COVENTRY TOWNSHIP OH
44319-3028
US

V. Phone/Fax

Practice location:
  • Phone: 330-608-1304
  • Fax:
Mailing address:
  • Phone: 330-608-1304
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.194020
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberAPS004935
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: