Provider Demographics
NPI:1851936116
Name:GRANT, COLLEEN MARIE
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MARIE
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 1:4286 EYOTA PL
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-3757
Mailing Address - Country:US
Mailing Address - Phone:951-312-9881
Mailing Address - Fax:
Practice Address - Street 1:4286 EYOTA PL
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-3757
Practice Address - Country:US
Practice Address - Phone:951-312-9881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-11
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician