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General NPI Number Information
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NPI Number | 1295111821
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Entity Type | Individual
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Provider Name | CAROLINE JENNIFER GRANTZ PH.D.
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Gender | Female
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Dates
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Enumeration Date | 08/05/2015
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Last Update Date | 08/05/2015
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Provider Practice Location Address
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Address Line | 1101 BROADWAY ST SUITE 230
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City | VANCOUVER
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State | WA
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Zip | 98660-3268
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Country | US
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Telephone | 559-313-3577
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Fax |
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Provider Business Mailing Address
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Address Line | 1547 SE 49TH AVE
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City | PORTLAND
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State | OR
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Zip | 97215-3221
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Country | US
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Telephone | 559-313-3577
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number | 60581664
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License Number State | WA
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