Provider Demographics
NPI:1053335414
Name:GRANT, CHERYN LEE (DO)
Entity Type:Individual
Prefix:
First Name:CHERYN
Middle Name:LEE
Last Name:GRANT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6663 SW BEAVERTON HILLSDALE HWY
Mailing Address - Street 2:PMB 291
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-1403
Mailing Address - Country:US
Mailing Address - Phone:503-296-6661
Mailing Address - Fax:503-296-6661
Practice Address - Street 1:4550 KRUSE WAY
Practice Address - Street 2:SUITE 225
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-3594
Practice Address - Country:US
Practice Address - Phone:503-296-6661
Practice Address - Fax:503-296-6661
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO120742084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR170274Medicaid
OR026WCGZLBMedicare ID - Type Unspecified
OR170274Medicaid