Provider Demographics
NPI:1407292162
Name:GRANNUM, GILLIAN (PHD)
Entity Type:Individual
Prefix:
First Name:GILLIAN
Middle Name:
Last Name:GRANNUM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:785 5TH AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:CHAMBERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17201-4232
Mailing Address - Country:US
Mailing Address - Phone:717-263-9555
Mailing Address - Fax:717-709-6529
Practice Address - Street 1:354 N READING RD
Practice Address - Street 2:
Practice Address - City:EPHRATA
Practice Address - State:PA
Practice Address - Zip Code:17522-1651
Practice Address - Country:US
Practice Address - Phone:717-738-1125
Practice Address - Fax:717-738-0606
Is Sole Proprietor?:No
Enumeration Date:2013-05-21
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS018690103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPS018690OtherSTATE LICENSE - PSYCHOLOGIST
14373031OtherCAQH ID
PA103573403Medicaid