Provider Demographics
NPI:1609074640
Name:GRANT, MATTHEW GREGORY (PSYD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:GREGORY
Last Name:GRANT
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:429 E VERMONT ST
Mailing Address - Street 2:307
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-3690
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:429 E VERMONT ST
Practice Address - Street 2:307
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-3690
Practice Address - Country:US
Practice Address - Phone:317-490-8179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-10
Last Update Date:2011-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042347A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist