Provider Demographics
NPI:1346581063
Name:GRUNDON, GRETCHEN STADNIK (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:STADNIK
Last Name:GRUNDON
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17597 MONTERO RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-2345
Mailing Address - Country:US
Mailing Address - Phone:858-208-7648
Mailing Address - Fax:
Practice Address - Street 1:11250 PENANOVA ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92129-1027
Practice Address - Country:US
Practice Address - Phone:858-699-7579
Practice Address - Fax:858-726-6021
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-05
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-12-12007103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst