Individual
GRANT MARTIN ELLISON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
35640 W MICHIGAN AVE, WAYNE, MI 48184-1628
(734) 729-7792
Mailing address
4763 GATEWOOD CIR, APT 3B, YPSILANTI, MI 48197-5035
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
6301016324
MI
Other
Enumeration date
06/29/2015
Last updated
06/29/2015
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