Provider Demographics
NPI:1194089862
Name:GRANT, GLORIA FAY
Entity type:Individual
Prefix:MS
First Name:GLORIA
Middle Name:FAY
Last Name:GRANT
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:GLORIA
Other - Middle Name:FAY
Other - Last Name:SUBORSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW,ACSW
Mailing Address - Street 1:5393 PAINTED PONY AVE
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:FL
Mailing Address - Zip Code:32666-8863
Mailing Address - Country:US
Mailing Address - Phone:352-473-6613
Mailing Address - Fax:352-473-1020
Practice Address - Street 1:5393 PAINTED PONY AVE
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:FL
Practice Address - Zip Code:32666-8863
Practice Address - Country:US
Practice Address - Phone:352-473-6613
Practice Address - Fax:352-473-1020
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-27
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW12081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL680256796Medicaid