Provider Demographics
NPI:1275692188
Name:SUSAN GRAYSEN PHD A PSYCHOLOGICAL CORPORATION
Entity Type:Organization
Organization Name:SUSAN GRAYSEN PHD A PSYCHOLOGICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAYSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:310-277-7838
Mailing Address - Street 1:10573 W PICO BLVD
Mailing Address - Street 2:# 242
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-2333
Mailing Address - Country:US
Mailing Address - Phone:310-277-7838
Mailing Address - Fax:310-559-9802
Practice Address - Street 1:9777 WILSHIRE BLVD STE 1007
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90212-1901
Practice Address - Country:US
Practice Address - Phone:310-277-7838
Practice Address - Fax:310-559-9802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY11434103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP11434Medicare ID - Type UnspecifiedOPT OUT INACTIVE