Provider Demographics
NPI:1720308075
Name:STOLL, GRANT E (PSYD)
Entity Type:Individual
Prefix:DR
First Name:GRANT
Middle Name:E
Last Name:STOLL
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8575 MORRO RD
Mailing Address - Street 2:SUITE K
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93422-3924
Mailing Address - Country:US
Mailing Address - Phone:805-466-5626
Mailing Address - Fax:805-466-2322
Practice Address - Street 1:8575 MORRO RD
Practice Address - Street 2:SUITE K
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-3924
Practice Address - Country:US
Practice Address - Phone:805-466-5626
Practice Address - Fax:805-466-2322
Is Sole Proprietor?:No
Enumeration Date:2010-06-09
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY23037103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist