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General NPI Number Information
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NPI Number | 1336967264
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Entity Type | Individual
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Provider Name | NICKHOLAS GRANT PH.D
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Gender | Male
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Dates
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Enumeration Date | 09/30/2024
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Last Update Date | 09/30/2024
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Provider Practice Location Address
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Address Line | 6222 AVALON DR W
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City | ORANGE
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State | CT
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Zip | 06477-3684
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Country | US
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Telephone | 203-701-6047
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Fax |
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Provider Business Mailing Address
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Address Line | 2389 MAIN ST STE 100
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City | GLASTONBURY
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State | CT
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Zip | 06033-4617
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 4836
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License Number State | CT
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