Healthcare Provider Details

I. General information

NPI: 1992320964
Provider Name (Legal Business Name): HARRY BURTON GRANT JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2020
Last Update Date: 10/14/2024
Certification Date: 10/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1207 E FRUIT ST
SANTA ANA CA
92701-4206
US

IV. Provider business mailing address

1207 E FRUIT ST
SANTA ANA CA
92701-4296
US

V. Phone/Fax

Practice location:
  • Phone: 714-953-9373
  • Fax: 714-953-7573
Mailing address:
  • Phone: 714-953-9373
  • Fax: 714-953-7573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number10513
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: