Provider Demographics
NPI:1710360573
Name:ELLISON, GRANT MARTIN
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:MARTIN
Last Name:ELLISON
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 1:4763 GATEWOOD CIR
Mailing Address - Street 2:APT 3B
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-5035
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:35640 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-1628
Practice Address - Country:US
Practice Address - Phone:734-729-7792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-29
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016324103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical