Provider Demographics
NPI:1336320126
Name:GRANT, MICHAEL MAXWELL (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:MAXWELL
Last Name:GRANT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 LODGE TRL
Mailing Address - Street 2:
Mailing Address - City:PAWLEYS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29585-7935
Mailing Address - Country:US
Mailing Address - Phone:843-655-5745
Mailing Address - Fax:843-314-3784
Practice Address - Street 1:74 LODGE TRL
Practice Address - Street 2:
Practice Address - City:PAWLEYS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29585-7935
Practice Address - Country:US
Practice Address - Phone:843-655-5745
Practice Address - Fax:843-314-3784
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-20
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1071103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1447436290Medicare UPIN