Provider Demographics
NPI:1437622883
Name:GRESHAM, MITCHELL LEE JR
Entity Type:Individual
Prefix:MR
First Name:MITCHELL
Middle Name:LEE
Last Name:GRESHAM
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 MOSS ST
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-2005
Mailing Address - Country:US
Mailing Address - Phone:619-585-4228
Mailing Address - Fax:
Practice Address - Street 1:1738 S TREMONT ST
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-5309
Practice Address - Country:US
Practice Address - Phone:619-601-8260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-08
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5250101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health