Provider Demographics
NPI:1235206657
Name:GRANT, RONALD B
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:B
Last Name:GRANT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1018 WOODPARK CT
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95116-3152
Mailing Address - Country:US
Mailing Address - Phone:408-294-0953
Mailing Address - Fax:408-294-7015
Practice Address - Street 1:20 S SANTA CRUZ AVE
Practice Address - Street 2:STE 310
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95030-6834
Practice Address - Country:US
Practice Address - Phone:408-294-0953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT 16313106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist