Healthcare Provider Details

I. General information

NPI: 1942121900
Provider Name (Legal Business Name): GRANT THOMSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25634 ALESSANDRO BLVD
MORENO VALLEY CA
92553-4916
US

IV. Provider business mailing address

1037 OLIVE AVE
BEAUMONT CA
92223-1645
US

V. Phone/Fax

Practice location:
  • Phone: 951-571-7500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number2793
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: