Healthcare Provider Details

I. General information

NPI: 1831715788
Provider Name (Legal Business Name): INGRID M GRANADOS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2020
Last Update Date: 09/13/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 SMITH RANCH RD
SAN RAFAEL CA
94903-1939
US

IV. Provider business mailing address

3426 LOWELL AVE
RICHMOND CA
94804-1168
US

V. Phone/Fax

Practice location:
  • Phone: 415-491-3000
  • Fax:
Mailing address:
  • Phone: 415-602-4477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: