MEDICARE: GRANT EDWARD BOOTH MSW, LICSW, ACSW

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	10829	MN

General Provider Information

NPI Number	:	1972504728
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRANT EDWARD BOOTH MSW, LICSW, ACSW

Provider Business Mailing Address
First Line	:	1499 LINCOLN AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-2236
Country	:	US
Telephone Number	:	651-690-1542
Fax Number	:	651-690-1451

Provider Business Practice Location Address
First Line	:	1499 LINCOLN AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-2236
Country	:	US
Telephone Number	:	651-690-1542
Fax Number	:	651-690-1451

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

Provider Enumeration Date	:	08/02/2005
Last Update Date	:	07/08/2007

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