Provider Demographics
NPI:1083836878
Name:GRIZZLE, STEPHEN MCRAE (M A)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:MCRAE
Last Name:GRIZZLE
Suffix:
Gender:M
Credentials:M A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 W PARR AVE
Mailing Address - Street 2:STE K
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-1442
Mailing Address - Country:US
Mailing Address - Phone:408-225-7914
Mailing Address - Fax:
Practice Address - Street 1:700 W PARR AVE
Practice Address - Street 2:STE K
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-1442
Practice Address - Country:US
Practice Address - Phone:408-225-7914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 25526106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist