Provider Demographics
NPI:1700456258
Name:DE LA GRANA, VICTOR M
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:M
Last Name:DE LA GRANA
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 1:1305 14TH AVE N
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33460-1715
Mailing Address - Country:US
Mailing Address - Phone:561-370-2629
Mailing Address - Fax:
Practice Address - Street 1:15924 SW 92ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33157-1842
Practice Address - Country:US
Practice Address - Phone:305-964-5824
Practice Address - Fax:786-452-1200
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker