=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154800290
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KERI INNIS-GRANT MSW PENDING
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2018
-----------------------------------------------------
Last Update Date | 08/09/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 108 GROVE STREET STE LL11
-----------------------------------------------------
City | WORCESTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-304-7499
-----------------------------------------------------
Fax | 774-420-7255
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 108 GROVE ST STE LL11
-----------------------------------------------------
City | WORCESTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01605-2677
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-304-7499
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 193200000X
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------