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NPI Code Detail

MEDICARE: MS. TRACY T GRANT PPS

MEDICARE: MS. TRACY T GRANT PPS
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
1103TS0200XSchool Psychologist2898CA

General Provider Information

NPI Number : 1083543334
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. TRACY T GRANT PPS
Provider Business Mailing Address
First Line : 11060 E LAS POSAS RD
Second Line :
City : SANTA ROSA VALLEY
State : CA
Zip : 93012-8838
Country : US
Telephone Number : 818-889-1262
Fax Number :
Provider Business Practice Location Address
First Line : 28545 DRIVER AVE
Second Line :
City : AGOURA HILLS
State : CA
Zip : 91301-3335
Country : US
Telephone Number : 818-889-1262
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/14/2026
Last Update Date : 05/14/2026

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