Healthcare Provider Details

I. General information

NPI: 1649780230
Provider Name (Legal Business Name): GRANT MICHAEL PATTERSON SUDRC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2017
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 W MISSION AVE STE 106
ESCONDIDO CA
92025-1603
US

IV. Provider business mailing address

8787 COMPLEX DR STE 300
SAN DIEGO CA
92123-1453
US

V. Phone/Fax

Practice location:
  • Phone: 619-281-3706
  • Fax: 760-796-4387
Mailing address:
  • Phone: 619-797-1090
  • Fax: 760-796-4397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number21935
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: