MEDICARE: KRISTIN GRANNIS MFTI 73996

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	112747	CA

General Provider Information

NPI Number	:	1619341773
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTIN GRANNIS MFTI 73996

Provider Business Mailing Address
First Line	:	PO BOX 1058
Second Line	:
City	:	AGOURA HILLS
State	:	CA
Zip	:	91376-1058
Country	:	US
Telephone Number	:	310-929-0935
Fax Number	:

Provider Business Practice Location Address
First Line	:	5158 CLARETON DR UNIT 1058
Second Line	:
City	:	AGOURA HILLS
State	:	CA
Zip	:	91376-7056
Country	:	US
Telephone Number	:	310-929-0935
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/30/2015
Last Update Date	:	12/04/2023

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