MEDICARE: MR. ROBERT MARK GRANT MS, BCBA

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	103K00000X	Behavior Analyst	1-12-11581	MA

General Provider Information

NPI Number	:	1558615633
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROBERT MARK GRANT MS, BCBA

Provider Business Mailing Address
First Line	:	98 OLD FARM RD
Second Line	:
City	:	LUNENBURG
State	:	MA
Zip	:	01462-1051
Country	:	US
Telephone Number	:	978-835-4776
Fax Number	:

Provider Business Practice Location Address
First Line	:	345A GREENWOOD ST
Second Line	:
City	:	WORCESTER
State	:	MA
Zip	:	01607-1753
Country	:	US
Telephone Number	:	508-363-0200
Fax Number	:

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

Provider Enumeration Date	:	10/29/2012
Last Update Date	:	10/02/2019

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