Provider Demographics
NPI:1821632365
Name:GRANT, THALIA JAZMEIRA
Entity Type:Individual
Prefix:
First Name:THALIA
Middle Name:JAZMEIRA
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 1:4025 W 226TH ST
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-2340
Mailing Address - Country:US
Mailing Address - Phone:310-373-4556
Mailing Address - Fax:
Practice Address - Street 1:4025 W 226TH ST
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-2340
Practice Address - Country:US
Practice Address - Phone:310-373-4556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-28
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CAAMFT141260106H00000X
CAAPCC14773101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional