Provider Demographics
NPI:1942678909
Name:GORDIN, GRANT BRADLEY
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:BRADLEY
Last Name:GORDIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1670 S AMPHLETT BLVD
Mailing Address - Street 2:SUITE 115
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-2510
Mailing Address - Country:US
Mailing Address - Phone:650-349-7969
Mailing Address - Fax:
Practice Address - Street 1:1670 S AMPHLETT BLVD
Practice Address - Street 2:SUITE 115
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402-2510
Practice Address - Country:US
Practice Address - Phone:650-349-7969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-08
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT INTERN #88136106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist