Provider Demographics
NPI:1073653085
Name:GRANT, REGENA MONIQUE
Entity Type:Individual
Prefix:MS
First Name:REGENA
Middle Name:MONIQUE
Last Name:GRANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:766 STALLION CIR
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-7718
Mailing Address - Country:US
Mailing Address - Phone:510-472-0979
Mailing Address - Fax:
Practice Address - Street 1:1441 CHINOOK CT UNIT C
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94130-1629
Practice Address - Country:US
Practice Address - Phone:415-398-2612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor