Provider Demographics
NPI:1295111821
Name:GRANTZ, CAROLINE JENNIFER (PHD)
Entity type:Individual
Prefix:
First Name:CAROLINE
Middle Name:JENNIFER
Last Name:GRANTZ
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 1:1547 SE 49TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-3221
Mailing Address - Country:US
Mailing Address - Phone:559-313-3577
Mailing Address - Fax:
Practice Address - Street 1:1101 BROADWAY ST
Practice Address - Street 2:SUITE 230
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98660-3268
Practice Address - Country:US
Practice Address - Phone:559-313-3577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-05
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60581664103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist