Basic Information
| Provider Information | |||||||||
| NPI: | 1497007652 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRANT | ||||||||
| FirstName: | VINTRICA | ||||||||
| MiddleName: | VICTORIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2821 LOU ANN DR. #209 | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2096227915 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1800 TULLY RD | ||||||||
| Address2: | SUITE F | ||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953502946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095761750 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2012 | ||||||||
| LastUpdateDate: | 12/03/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 36652 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.