Provider Demographics
NPI:1689705196
Name:GRANUCCI, VICTORIA C (PHD)
Entity Type:Individual
Prefix:DR
First Name:VICTORIA
Middle Name:C
Last Name:GRANUCCI
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1036 SIR FRANCIS DRAKE BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:KENTFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94904-1427
Mailing Address - Country:US
Mailing Address - Phone:415-460-0441
Mailing Address - Fax:415-453-4514
Practice Address - Street 1:1036 SIR FRANCIS DRAKE BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:KENTFIELD
Practice Address - State:CA
Practice Address - Zip Code:94904-1427
Practice Address - Country:US
Practice Address - Phone:415-460-0441
Practice Address - Fax:415-453-4514
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18074103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PL180740Medicare ID - Type UnspecifiedPROVIDER