Provider Demographics
NPI:1003113622
Name:GREDVIG, CHANNING (LCSW)
Entity Type:Individual
Prefix:
First Name:CHANNING
Middle Name:
Last Name:GREDVIG
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3420 KENYON ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-5001
Mailing Address - Country:US
Mailing Address - Phone:619-221-6550
Mailing Address - Fax:619-221-6556
Practice Address - Street 1:3420 KENYON ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-5001
Practice Address - Country:US
Practice Address - Phone:619-221-6550
Practice Address - Fax:619-221-6556
Is Sole Proprietor?:No
Enumeration Date:2011-02-16
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA646511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical