Healthcare Provider Details

I. General information

NPI: 1710360573
Provider Name (Legal Business Name): GRANT MARTIN ELLISON MS LLP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2015
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5340 PLYMOUTH RD STE 202
ANN ARBOR MI
48105-9341
US

IV. Provider business mailing address

1055 ALAMO CT
TECUMSEH MI
49286-9709
US

V. Phone/Fax

Practice location:
  • Phone: 734-462-3210
  • Fax:
Mailing address:
  • Phone: 989-313-0919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6361005291
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: