Healthcare Provider Details

I. General information

NPI: 1073006904
Provider Name (Legal Business Name): COURTNEY GRANDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2018
Last Update Date: 12/27/2021
Certification Date: 12/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2216 SAN GORGONIO RD
LA CANADA CA
91011-1351
US

IV. Provider business mailing address

2216 SAN GORGONIO RD
LA CANADA CA
91011-1351
US

V. Phone/Fax

Practice location:
  • Phone: 818-967-9754
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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 TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: