Provider Demographics
NPI:1659028181
Name:GRIGORYAN, ROMAN B
Entity Type:Individual
Prefix:
First Name:ROMAN
Middle Name:B
Last Name:GRIGORYAN
Suffix:
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 1:1305 DEL NORTE RD
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-8436
Mailing Address - Country:US
Mailing Address - Phone:805-654-9814
Mailing Address - Fax:
Practice Address - Street 1:1305 DEL NORTE RD
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-8436
Practice Address - Country:US
Practice Address - Phone:805-654-9814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-04
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty