Healthcare Provider Details

I. General information

NPI: 1164275764
Provider Name (Legal Business Name): MADELINE GRANT LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2024
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1416 MONROE AVE
DUNMORE PA
18509-2477
US

IV. Provider business mailing address

62 HILDEBRANDT RD
DALLAS PA
18612-9058
US

V. Phone/Fax

Practice location:
  • Phone: 570-483-8956
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW026496
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSW140610
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: