MEDICARE: PHILIP GRANDE LMFT

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	106H00000X	Marriage & Family Therapist	LMFT44227	CA

General Provider Information

NPI Number	:	1811650666
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHILIP GRANDE LMFT

Provider Business Mailing Address
First Line	:	29421 ROCKY CANYON DR
Second Line	:
City	:	LAKE ELSINORE
State	:	CA
Zip	:	92530-7273
Country	:	US
Telephone Number	:	626-255-1143
Fax Number	:

Provider Business Practice Location Address
First Line	:	29421 ROCKY CANYON DR
Second Line	:
City	:	LAKE ELSINORE
State	:	CA
Zip	:	92530-7273
Country	:	US
Telephone Number	:	626-255-1143
Fax Number	:

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

Provider Enumeration Date	:	10/19/2021
Last Update Date	:	10/19/2021

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