Healthcare Provider Details

I. General information

NPI: 1508771502
Provider Name (Legal Business Name): VENICE J GRANT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2453 GRAND CANAL BLVD STE 216
STOCKTON CA
95207-8138
US

IV. Provider business mailing address

5517 VINTAGE CIR
STOCKTON CA
95219-2510
US

V. Phone/Fax

Practice location:
  • Phone: 209-800-7611
  • Fax:
Mailing address:
  • Phone: 209-800-7611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. VENICE J GRANT
Title or Position: CLINICAL DIRECTOR
Credential: PSYD
Phone: 510-875-3752