MEDICARE: DR. JOHN MICHAEL GRANSBACH DNP, APRN, PMHNP-BC

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	2084P0015X	Psychosomatic Medicine Physician	2023024715	MO
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	RN321441	GA

General Provider Information

NPI Number	:	1265118343
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN MICHAEL GRANSBACH DNP, APRN, PMHNP-BC

Provider Business Mailing Address
First Line	:	1605 CHANTILLY DR NE STE 110
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30324-3277
Country	:	US
Telephone Number	:	404-785-5437
Fax Number	:

Provider Business Practice Location Address
First Line	:	1605 CHANTILLY DR NE STE 110
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30324-3277
Country	:	US
Telephone Number	:	404-785-5437
Fax Number	:

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

Provider Enumeration Date	:	06/23/2023
Last Update Date	:	10/05/2023

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