Provider Demographics
NPI:1437465705
Name:LEITHEISER, GRANT SCOT (LMFT, PPSC)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:SCOT
Last Name:LEITHEISER
Suffix:
Gender:M
Credentials:LMFT, PPSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3468 MT DIABLO BLVD
Mailing Address - Street 2:SUITE B201
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-3957
Mailing Address - Country:US
Mailing Address - Phone:925-297-5161
Mailing Address - Fax:
Practice Address - Street 1:3468 MT DIABLO BLVD
Practice Address - Street 2:SUITE B200
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-3957
Practice Address - Country:US
Practice Address - Phone:925-297-5161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-25
Last Update Date:2013-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 52224106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist