MEDICARE: MR. CHARLES R GRANHOLM JR. LCSW

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	1041C0700X	Clinical Social Worker	1308	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1308	OTHER	KY	STATE LICENSE
2	34004318A	OTHER	IN	STATE LICENSE

General Provider Information

NPI Number	:	1619953213
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHARLES R GRANHOLM JR. LCSW

Provider Business Mailing Address
First Line	:	200 BRULE ST BLDG 871
Second Line	:
City	:	FORT KNOX
State	:	KY
Zip	:	40121-6100
Country	:	US
Telephone Number	:	502-626-9877
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 BRULE ST BLDG IRELAND
Second Line	:
City	:	FORT KNOX
State	:	KY
Zip	:	40121-6100
Country	:	US
Telephone Number	:	502-626-9885
Fax Number	:

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

Provider Enumeration Date	:	12/16/2005
Last Update Date	:	12/04/2023

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Directions to “ MR. CHARLES R GRANHOLM JR. LCSW” Practice Location

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