Provider Demographics
NPI:1871734756
Name:GRAN, MARISSA ILENE (PHD)
Entity type:Individual
Prefix:DR
First Name:MARISSA
Middle Name:ILENE
Last Name:GRAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3525 DEL MAR HEIGHTS RD # 115
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-2199
Mailing Address - Country:US
Mailing Address - Phone:619-500-2104
Mailing Address - Fax:
Practice Address - Street 1:1940 GARNET AVE STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-3575
Practice Address - Country:US
Practice Address - Phone:619-500-2104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-23
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY33066103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical