Provider Demographics
NPI:1558001065
Name:GRANDIN, DAVID ANDREW (MFCC)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:ANDREW
Last Name:GRANDIN
Suffix:
Gender:M
Credentials:MFCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 MOREY DR # 203B
Mailing Address - Street 2:
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-5123
Mailing Address - Country:US
Mailing Address - Phone:650-207-5705
Mailing Address - Fax:
Practice Address - Street 1:540 MOREY DR # 203B
Practice Address - Street 2:
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-5123
Practice Address - Country:US
Practice Address - Phone:650-207-5705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-31
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMT20066101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA12345678910Medicaid