Basic Information
| Provider Information | |||||||||
| NPI: | 1992838221 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRANT | ||||||||
| FirstName: | CHRISTYN | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 407 MULBERRY ST SW | ||||||||
| Address2: | |||||||||
| City: | LENOIR | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286455722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283946720 | ||||||||
| FaxNumber: | 8283946721 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 WILLOW LN | ||||||||
| Address2: | |||||||||
| City: | NORTH WILKESBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286593551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3366675151 | ||||||||
| FaxNumber: | 3366675048 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2007 | ||||||||
| LastUpdateDate: | 12/16/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C005688 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 6106729 | 05 | NC | MEDICAID | C005688 | 01 | NC | LCSW | OTHER |