Provider Demographics
NPI:1811650666
Name:GRANDE, PHILIP (LMFT)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:GRANDE
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29421 ROCKY CANYON DR
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-7273
Mailing Address - Country:US
Mailing Address - Phone:626-255-1143
Mailing Address - Fax:
Practice Address - Street 1:29421 ROCKY CANYON DR
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-7273
Practice Address - Country:US
Practice Address - Phone:626-255-1143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-19
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT44227106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist