Provider Demographics
NPI:1851301956
Name:MOSES, GRANT (MFT INTERN)
Entity Type:Individual
Prefix:MR
First Name:GRANT
Middle Name:
Last Name:MOSES
Suffix:
Gender:M
Credentials:MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5277 SONORA WAY
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608
Mailing Address - Country:US
Mailing Address - Phone:916-779-2411
Mailing Address - Fax:916-641-9599
Practice Address - Street 1:3951 PERFORMANCE DR STE G
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95838-3264
Practice Address - Country:US
Practice Address - Phone:916-921-0828
Practice Address - Fax:916-921-0333
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45309106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist