Provider Demographics
NPI:1386737609
Name:GRANT, JOHN ELWOOD (PSYD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ELWOOD
Last Name:GRANT
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:PO BOX 170116
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94117-0116
Mailing Address - Country:US
Mailing Address - Phone:808-349-9548
Mailing Address - Fax:415-358-5604
Practice Address - Street 1:1947 DIVISADERO ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-2532
Practice Address - Country:US
Practice Address - Phone:415-420-5824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19317103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL193170Medicare UPIN