Provider Demographics
NPI:1407615248
Name:GRANT, WANISHA
Entity type:Individual
Prefix:MS
First Name:WANISHA
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 ROUNDTABLE DR APT 10
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95111-4119
Mailing Address - Country:US
Mailing Address - Phone:408-813-7703
Mailing Address - Fax:
Practice Address - Street 1:109 ROUNDTABLE DR APT 10
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95111-4119
Practice Address - Country:US
Practice Address - Phone:408-813-7703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-14
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician