Provider Demographics
NPI:1548388010
Name:GRANT, GORDON ANTONELLI
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:ANTONELLI
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 1:22262 S GARDEN AVE APT 104
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94541-6025
Mailing Address - Country:US
Mailing Address - Phone:510-978-9655
Mailing Address - Fax:
Practice Address - Street 1:22262 S GARDEN AVE APT 104
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94541-6025
Practice Address - Country:US
Practice Address - Phone:510-978-9655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health