Provider Demographics
NPI:1962734384
Name:GRANT, ELLEN ELIZABETH (MSW)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:ELIZABETH
Last Name:GRANT
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 NIAGARA ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14213-1503
Mailing Address - Country:US
Mailing Address - Phone:716-308-6328
Mailing Address - Fax:
Practice Address - Street 1:1300 NIAGARA ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14213-1503
Practice Address - Country:US
Practice Address - Phone:716-308-6328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-10
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR019331-1103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst