Provider Demographics
NPI:1215030358
Name:HAMILTON, MARYANNE GRANDE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARYANNE
Middle Name:GRANDE
Last Name:HAMILTON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1498 EAST AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14610
Mailing Address - Country:US
Mailing Address - Phone:585-442-3415
Mailing Address - Fax:
Practice Address - Street 1:760 PERINTON HILLS OFFICE PARK
Practice Address - Street 2:
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450
Practice Address - Country:US
Practice Address - Phone:585-223-5920
Practice Address - Fax:585-223-5727
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004209103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY100140FCOtherPREFERRED CARE
NY7408318Medicaid
NYRA0189Medicare ID - Type Unspecified
NY7408318Medicaid