MEDICARE: NICOLE GRANT

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	235Z00000X	Speech-Language Pathologist

General Provider Information

NPI Number	:	1689228165
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE GRANT

Provider Business Mailing Address
First Line	:	450 N BURGHER AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10310-2049
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	450 N BURGHER AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10310-2049
Country	:	US
Telephone Number	:	646-709-1545
Fax Number	:

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

Provider Enumeration Date	:	08/01/2019
Last Update Date	:	03/08/2026

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Directions to “ NICOLE GRANT ” Practice Location

Language	Start Address	Practice Location

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