Provider Demographics
NPI:1386480085
Name:CORSO, GRANT (MA)
Entity type:Individual
Prefix:MR
First Name:GRANT
Middle Name:
Last Name:CORSO
Suffix:
Gender:M
Credentials:MA
Other - Prefix:MR
Other - First Name:IZAN
Other - Middle Name:
Other - Last Name:CORSO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:7855 FAY AVE
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-4265
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7855 FAY AVE STE 310
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-4280
Practice Address - Country:US
Practice Address - Phone:619-953-7484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-02
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health