Provider Demographics
NPI:1568080745
Name:GRAMMER, NIKOLAI IVANOV (ADT)
Entity Type:Individual
Prefix:
First Name:NIKOLAI
Middle Name:IVANOV
Last Name:GRAMMER
Suffix:
Gender:M
Credentials:ADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 W AYLESBURY RD
Mailing Address - Street 2:
Mailing Address - City:TIMONIUM
Mailing Address - State:MD
Mailing Address - Zip Code:21093-4101
Mailing Address - Country:US
Mailing Address - Phone:410-561-9591
Mailing Address - Fax:410-561-9396
Practice Address - Street 1:2 W AYLESBURY RD
Practice Address - Street 2:
Practice Address - City:TIMONIUM
Practice Address - State:MD
Practice Address - Zip Code:21093-4101
Practice Address - Country:US
Practice Address - Phone:410-561-9591
Practice Address - Fax:410-561-9396
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-14
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD101YA0400X
MD1981101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)