Healthcare Provider Details

I. General information

NPI: 1306090642
Provider Name (Legal Business Name): ANA LILIA SOTO GRANT LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2008
Last Update Date: 06/17/2021
Certification Date: 06/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1014 SAN JUAN AVE
EXETER CA
93221-1312
US

IV. Provider business mailing address

4910 E ASHLAN AVE STE 118
FRESNO CA
93726-3021
US

V. Phone/Fax

Practice location:
  • Phone: 559-592-7300
  • Fax:
Mailing address:
  • Phone: 559-256-4474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number90322
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: