MEDICARE: MS. SALLY L GRANT LCAS

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	1390	NC

General Provider Information

NPI Number	:	1255570289
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SALLY L GRANT LCAS

Provider Business Mailing Address
First Line	:	2719 GRAVES DR STE 7
Second Line	:
City	:	GOLDSBORO
State	:	NC
Zip	:	27534-4536
Country	:	US
Telephone Number	:	919-583-8448
Fax Number	:	919-583-8449

Provider Business Practice Location Address
First Line	:	2719 GRAVES DR STE 7
Second Line	:
City	:	GOLDSBORO
State	:	NC
Zip	:	27534-4536
Country	:	US
Telephone Number	:	919-583-8448
Fax Number	:	919-583-8449

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

Provider Enumeration Date	:	02/14/2009
Last Update Date	:	02/14/2009

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