Provider Demographics
NPI:1538368444
Name:GRANT, WANDA FELICIA (PHD)
Entity type:Individual
Prefix:DR
First Name:WANDA
Middle Name:FELICIA
Last Name:GRANT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:WANDA
Other - Middle Name:FELICIA
Other - Last Name:GRANT-KNIGHT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:345 EAST SUPERIOR STREET
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60190
Mailing Address - Country:US
Mailing Address - Phone:312-238-2897
Mailing Address - Fax:
Practice Address - Street 1:345 EAST SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611
Practice Address - Country:US
Practice Address - Phone:312-238-2897
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist