Provider Demographics
NPI:1760551949
Name:MARTIN, GRANT L (PHD)
Entity Type:Individual
Prefix:DR
First Name:GRANT
Middle Name:L
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 DAYTON ST STE C
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98020-3476
Mailing Address - Country:US
Mailing Address - Phone:425-774-4673
Mailing Address - Fax:425-774-0690
Practice Address - Street 1:555 DAYTON ST STE C
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98020-3476
Practice Address - Country:US
Practice Address - Phone:425-774-4673
Practice Address - Fax:425-774-0690
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA596103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA1172OtherREGENCE BLUESHIELD RIDER#