Provider Demographics
NPI:1023646981
Name:GRUNERT, RICHARD ROBERT (RADT#R1341210319)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:ROBERT
Last Name:GRUNERT
Suffix:
Gender:M
Credentials:RADT#R1341210319
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:668 CHEVY CHASE WAY
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94544-7230
Mailing Address - Country:US
Mailing Address - Phone:650-921-8631
Mailing Address - Fax:
Practice Address - Street 1:550 QUARRY RD
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070-6221
Practice Address - Country:US
Practice Address - Phone:650-921-8631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-27
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 172V00000X
CAR1341210319171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator