Provider Demographics
NPI:1760635213
Name:GRANDERSON, KAYLA
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:GRANDERSON
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 1:9343 TECH CENTER DR FL 2
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95826-2563
Mailing Address - Country:US
Mailing Address - Phone:916-641-9595
Mailing Address - Fax:
Practice Address - Street 1:9343 TECH CENTER DR FL 2
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95826-2563
Practice Address - Country:US
Practice Address - Phone:916-641-9595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist