Healthcare Provider Details

I. General information

NPI: 1740782812
Provider Name (Legal Business Name): ASHLEY GRANT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2018
Last Update Date: 09/15/2021
Certification Date: 09/15/2021
Deactivation Date: 08/23/2019
Reactivation Date: 08/20/2021

III. Provider practice location address

112 JAGLA ST
COTATI CA
94931-5407
US

IV. Provider business mailing address

PO BOX 261
COTATI CA
94931-0261
US

V. Phone/Fax

Practice location:
  • Phone: 415-993-0553
  • Fax:
Mailing address:
  • Phone: 415-993-0553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number105584
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: