Provider Demographics
NPI:1700324415
Name:GRANISH, PHILIP RICHARD (LLP)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:RICHARD
Last Name:GRANISH
Suffix:
Gender:M
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4384 LAUREL DRIVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4341 S. WESTNEDGE
Practice Address - Street 2:SUITE 1103
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008
Practice Address - Country:US
Practice Address - Phone:269-982-3832
Practice Address - Fax:269-281-0351
Is Sole Proprietor?:No
Enumeration Date:2017-02-02
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361006461103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI43191OtherMICHIGAN DEPARTMENT OF CORRECTIONS PROVIDER ID NUMBER