Provider Demographics
NPI:1629029434
Name:GRANT, MARY CHRISTINE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:CHRISTINE
Last Name:GRANT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1655 ELMWOOD AVE
Mailing Address - Street 2:STE 135
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620
Mailing Address - Country:US
Mailing Address - Phone:585-271-3600
Mailing Address - Fax:585-271-1017
Practice Address - Street 1:1655 ELMWOOD AVE
Practice Address - Street 2:STE 135
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620
Practice Address - Country:US
Practice Address - Phone:585-271-3600
Practice Address - Fax:585-271-1017
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-15
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5619103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
100193FCOtherPREFERRED CARE
P010005619OtherEXCELLUS
R55221Medicare UPIN
10113BMedicare ID - Type Unspecified