Provider Demographics
NPI:1871753749
Name:GRANT, LATEASHA
Entity type:Individual
Prefix:
First Name:LATEASHA
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 TANGLEWOOD CT.
Mailing Address - Street 2:
Mailing Address - City:MONMOUTH JUNCTION
Mailing Address - State:NJ
Mailing Address - Zip Code:08852
Mailing Address - Country:US
Mailing Address - Phone:973-493-2323
Mailing Address - Fax:
Practice Address - Street 1:8 TANGLEWOOD CT.
Practice Address - Street 2:
Practice Address - City:MONMOUTH JUNCTION
Practice Address - State:NJ
Practice Address - Zip Code:08852
Practice Address - Country:US
Practice Address - Phone:973-493-2323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-13
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC056333001041C0700X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1871753749Medicaid
NJ1871753749Medicare NSC
NJ1871753749Medicaid