Provider Demographics
NPI:1598236671
Name:GRANSTROM, ZACHERY
Entity Type:Individual
Prefix:
First Name:ZACHERY
Middle Name:
Last Name:GRANSTROM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 FAWCETT AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-5502
Mailing Address - Country:US
Mailing Address - Phone:253-258-4770
Mailing Address - Fax:
Practice Address - Street 1:1421 S 53RD ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98408-3546
Practice Address - Country:US
Practice Address - Phone:253-258-4770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health