Provider Demographics
NPI:1124858329
Name:GRANT, NICHOLOS (LPC)
Entity type:Individual
Prefix:
First Name:NICHOLOS
Middle Name:
Last Name:GRANT
Suffix:
Gender:
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 746722
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6722
Mailing Address - Country:US
Mailing Address - Phone:773-352-1515
Mailing Address - Fax:
Practice Address - Street 1:2401 W CHELTENHAM AVE
Practice Address - Street 2:
Practice Address - City:WYNCOTE
Practice Address - State:PA
Practice Address - Zip Code:19095-2946
Practice Address - Country:US
Practice Address - Phone:215-444-7471
Practice Address - Fax:215-695-2935
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-03
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC017383101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional