Provider Demographics
NPI:1164161352
Name:GRAYSON, KRISA ESTELLA (PLADC)
Entity Type:Individual
Prefix:MRS
First Name:KRISA
Middle Name:ESTELLA
Last Name:GRAYSON
Suffix:
Gender:F
Credentials:PLADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4402 PINKNEY ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68111-2530
Mailing Address - Country:US
Mailing Address - Phone:402-880-9333
Mailing Address - Fax:
Practice Address - Street 1:4200 N 30TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68111-2424
Practice Address - Country:US
Practice Address - Phone:402-880-9333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-03
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEP-1826101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
000123OtherNO CLIENTS TO DATE