Healthcare Provider Details

I. General information

NPI: 1497007652
Provider Name (Legal Business Name): VINTRICA VICTORIA GRANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2012
Last Update Date: 12/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 TULLY RD SUITE F
MODESTO CA
95350-2946
US

IV. Provider business mailing address

2821 LOU ANN DR. #209
MODESTO CA
95350
US

V. Phone/Fax

Practice location:
  • Phone: 209-576-1750
  • Fax:
Mailing address:
  • Phone: 209-622-7915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number36652
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: