=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285649061
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VICTORIA V GRANTHAM MSW, LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2006
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 GLENWAY ST SUITE B
-----------------------------------------------------
City | BELMONT
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28012-3173
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-829-2005
-----------------------------------------------------
Fax | 704-829-2006
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 GLENWAY ST SUITE B
-----------------------------------------------------
City | BELMONT
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28012-3173
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-829-2005
-----------------------------------------------------
Fax | 704-829-2006
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | C005362
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------