MEDICARE: GREY R LARISON PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	6301001732	MI
2	103G00000X	Clinical Neuropsychologist	6301001732	MI

General Provider Information

NPI Number	:	1841226297
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREY R LARISON PH.D.

Provider Business Mailing Address
First Line	:	300 68TH ST SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49548-6927
Country	:	US
Telephone Number	:	616-455-5000
Fax Number	:

Provider Business Practice Location Address
First Line	:	9090 S RODGERS CT SE
Second Line	:
City	:	CALEDONIA
State	:	MI
Zip	:	49316-8052
Country	:	US
Telephone Number	:	616-891-8770
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/25/2006
Last Update Date	:	09/11/2025

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