Provider Demographics
NPI:1740782812
Name:GRANT, ASHLEY
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:GRANT
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:PO BOX 261
Mailing Address - Street 2:
Mailing Address - City:COTATI
Mailing Address - State:CA
Mailing Address - Zip Code:94931-0261
Mailing Address - Country:US
Mailing Address - Phone:415-993-0553
Mailing Address - Fax:
Practice Address - Street 1:112 JAGLA ST
Practice Address - Street 2:
Practice Address - City:COTATI
Practice Address - State:CA
Practice Address - Zip Code:94931-5407
Practice Address - Country:US
Practice Address - Phone:415-993-0553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-05
Last Update Date:2021-09-15
Deactivation Date:2019-08-23
Deactivation Code:
Reactivation Date:2021-08-20
Provider Licenses
StateLicense IDTaxonomies
CA105584106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist