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General NPI Number Information
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NPI Number | 1871734756
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Entity Type | Individual
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Provider Name | MARISSA ILENE GRAN PHD
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Gender | Female
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Dates
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Enumeration Date | 03/23/2009
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Last Update Date | 12/07/2022
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Provider Practice Location Address
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Address Line | 1940 GARNET AVE STE 100
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City | SAN DIEGO
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State | CA
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Zip | 92109-3575
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Country | US
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Telephone | 619-500-2104
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Fax |
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Provider Business Mailing Address
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Address Line | 3525 DEL MAR HEIGHTS RD # 115
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City | SAN DIEGO
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State | CA
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Zip | 92130-2199
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Country | US
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Telephone | 619-500-2104
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY33066
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License Number State | CA
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