Healthcare Provider Details

I. General information

NPI: 1124577002
Provider Name (Legal Business Name): GRANTLEY SAMUELS SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2016
Last Update Date: 08/25/2025
Certification Date: 08/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1263 MISSION ST
SAN FRANCISCO CA
94103-2705
US

IV. Provider business mailing address

1263 MISSION STREET, SAN FRANCISCO, CA 94103
SAN FRANCISCO CA
94103
US

V. Phone/Fax

Practice location:
  • Phone: 415-650-6064
  • Fax:
Mailing address:
  • Phone: 628-222-9790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number19786
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: