Provider Demographics
NPI:1093194169
Name:GRAYSON, WILLIAM G (CADC I/QMHA)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:G
Last Name:GRAYSON
Suffix:
Gender:M
Credentials:CADC I/QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 S PALMETTO ST
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:OR
Mailing Address - Zip Code:97113-6252
Mailing Address - Country:US
Mailing Address - Phone:503-359-1495
Mailing Address - Fax:
Practice Address - Street 1:720 SE WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4230
Practice Address - Country:US
Practice Address - Phone:503-648-0753
Practice Address - Fax:503-648-0755
Is Sole Proprietor?:No
Enumeration Date:2015-05-22
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
OR99-11-15101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500729527Medicaid
OR500729451Medicaid