Provider Demographics
NPI:1427588474
Name:GRANT, REBECCA MARIE
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:MARIE
Last Name:GRANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:MARIE
Other - Last Name:DORSEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:900 FAIRVIEW ST SE STE D13
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-1875
Mailing Address - Country:US
Mailing Address - Phone:360-754-5729
Mailing Address - Fax:360-943-2659
Practice Address - Street 1:6128 CAPITOL BLVD SE
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98501-5271
Practice Address - Country:US
Practice Address - Phone:360-754-5729
Practice Address - Fax:360-943-2659
Is Sole Proprietor?:No
Enumeration Date:2017-06-13
Last Update Date:2017-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60727725101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health