Provider Demographics
NPI:1063453439
Name:GRANT, MITZIE L (PHD)
Entity Type:Individual
Prefix:DR
First Name:MITZIE
Middle Name:L
Last Name:GRANT
Suffix:
Gender:F
Credentials:PHD
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Other - First Name:
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Mailing Address - Street 1:1601 CHERRY ST
Mailing Address - Street 2:SUITE 11511
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-1321
Mailing Address - Country:US
Mailing Address - Phone:215-255-7822
Mailing Address - Fax:215-255-7825
Practice Address - Street 1:4641 ROOSEVELT BLVD
Practice Address - Street 2:SUITE C229
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19124-2343
Practice Address - Country:US
Practice Address - Phone:215-831-4811
Practice Address - Fax:215-831-2603
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAPS008501L103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001685355Medicaid
PA001685355Medicaid
PAS54047Medicare UPIN