Provider Demographics
NPI:1679965206
Name:PADAMADA, GRIZELLI-SHANE (APCC)
Entity Type:Individual
Prefix:MISS
First Name:GRIZELLI-SHANE
Middle Name:
Last Name:PADAMADA
Suffix:
Gender:F
Credentials:APCC
Other - Prefix:MISS
Other - First Name:SHANE
Other - Middle Name:
Other - Last Name:PADAMADA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APCC
Mailing Address - Street 1:730 MEDICAL CENTER CT
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-6618
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:730 MEDICAL CENTER CT
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-6618
Practice Address - Country:US
Practice Address - Phone:619-934-1291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-18
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health