Provider Demographics
NPI:1609651934
Name:GRANDOLFO, REIGHAN
Entity Type:Individual
Prefix:
First Name:REIGHAN
Middle Name:
Last Name:GRANDOLFO
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 1:1415 N COLLEGE AVE # E108
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-3156
Mailing Address - Country:US
Mailing Address - Phone:317-918-3865
Mailing Address - Fax:
Practice Address - Street 1:1415 N COLLEGE AVE # E108
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-3156
Practice Address - Country:US
Practice Address - Phone:317-918-3865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-25
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty