Provider Demographics
NPI:1154800290
Name:INNIS-GRANT, KERI (MSW PENDING)
Entity type:Individual
Prefix:
First Name:KERI
Middle Name:
Last Name:INNIS-GRANT
Suffix:
Gender:F
Credentials:MSW PENDING
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 GROVE ST STE LL11
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-2677
Mailing Address - Country:US
Mailing Address - Phone:508-304-7499
Mailing Address - Fax:
Practice Address - Street 1:108 GROVE STREET
Practice Address - Street 2:STE LL11
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605
Practice Address - Country:US
Practice Address - Phone:508-304-7499
Practice Address - Fax:774-420-7255
Is Sole Proprietor?:No
Enumeration Date:2018-08-09
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA193200000X101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional