Healthcare Provider Details

I. General information

NPI: 1750500237
Provider Name (Legal Business Name): GRANITE WELLNESS CENTERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 09/22/2022
Certification Date: 09/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 SIERRA COLLEGE DR
GRASS VALLEY CA
95945-5768
US

IV. Provider business mailing address

PO BOX 6028
AUBURN CA
95604-6028
US

V. Phone/Fax

Practice location:
  • Phone: 530-273-9541
  • Fax: 530-273-7740
Mailing address:
  • Phone: 530-878-5166
  • Fax: 916-797-8979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number290002AN
License Number StateCA

VIII. Authorized Official

Name: ELAINE EBBERT
Title or Position: OPERATIONS DIRECTOR
Credential:
Phone: 530-878-5166