Provider Demographics
NPI:1881343986
Name:WETTELAND, GRANT
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:WETTELAND
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 1:6141 INGLESTON DR APT 821
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89436-7058
Mailing Address - Country:US
Mailing Address - Phone:909-529-3832
Mailing Address - Fax:
Practice Address - Street 1:975 ROBERTA LN STE 104
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89431-6812
Practice Address - Country:US
Practice Address - Phone:775-525-1616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-23
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist