Basic Information
| Provider Information | |||||||||
| NPI: | 1003158502 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MYERS | ||||||||
| FirstName: | GRANT | ||||||||
| MiddleName: | MARSHALL | ||||||||
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| Credential: | PMHNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 RESEARCH PKWY | ||||||||
| Address2: | |||||||||
| City: | OLD SAYBROOK | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064754214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003703651 | ||||||||
| FaxNumber: | 8605100020 | ||||||||
| Practice Location | |||||||||
| Address1: | 830 BEAR TAVERN RD | ||||||||
| Address2: | |||||||||
| City: | EWING | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 086281020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003703651 | ||||||||
| FaxNumber: | 8605100020 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2013 | ||||||||
| LastUpdateDate: | 04/29/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 26NJ00419200 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.