Provider Demographics
NPI:1750812152
Name:GRANNEMANN, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:GRANNEMANN
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 1:921 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2316
Mailing Address - Country:US
Mailing Address - Phone:360-423-0203
Mailing Address - Fax:360-577-0269
Practice Address - Street 1:6128 CAPITOL BLVD SE
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98501-5271
Practice Address - Country:US
Practice Address - Phone:360-704-7170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-27
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60154298101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health