MEDICARE: MARCIA K GRANT LCSW LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	34001472A	IN

General Provider Information

NPI Number	:	1013076413
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARCIA K GRANT LCSW LMFT

Provider Business Mailing Address
First Line	:	415 E COOK RD
Second Line	:	SUITE 100
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-3636
Country	:	US
Telephone Number	:	260-489-6030
Fax Number	:	260-489-5536

Provider Business Practice Location Address
First Line	:	415 E COOK RD
Second Line	:	SUITE 100
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-3636
Country	:	US
Telephone Number	:	260-489-6030
Fax Number	:	260-489-5536

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/08/2006
Last Update Date	:	11/02/2015

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