Healthcare Provider Details

I. General information

NPI: 1205129020
Provider Name (Legal Business Name): CHANEL RUTH GRANT LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2011
Last Update Date: 05/22/2025
Certification Date: 05/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 SHADOWRIDGE DR
VISTA CA
92083-7986
US

IV. Provider business mailing address

780 SHADOWRIDGE DR
VISTA CA
92083-7986
US

V. Phone/Fax

Practice location:
  • Phone: 833-579-4848
  • Fax: 760-599-2399
Mailing address:
  • Phone: 833-579-4848
  • Fax: 760-599-2399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT90860
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: