Provider Demographics
NPI:1063869337
Name:GRANT, KATELYN MAE (MS, LPC, NCC)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:MAE
Last Name:GRANT
Suffix:
Gender:F
Credentials:MS, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18205 N 51ST AVE STE 136
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-1492
Mailing Address - Country:US
Mailing Address - Phone:480-640-2998
Mailing Address - Fax:866-340-1836
Practice Address - Street 1:18205 N 51ST AVE STE 136
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-1492
Practice Address - Country:US
Practice Address - Phone:480-640-2998
Practice Address - Fax:866-340-1836
Is Sole Proprietor?:No
Enumeration Date:2016-05-17
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3012-226101YM0800X
AZLPC-18282101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health