Provider Demographics
NPI:1689897068
Name:GRISHAM, DWIGHT H (MA,EDS, EDD)
Entity Type:Individual
Prefix:DR
First Name:DWIGHT
Middle Name:H
Last Name:GRISHAM
Suffix:
Gender:M
Credentials:MA,EDS, EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 NEW MONTGOMERY ST
Mailing Address - Street 2:SUITE 725
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94105-3412
Mailing Address - Country:US
Mailing Address - Phone:415-543-2418
Mailing Address - Fax:
Practice Address - Street 1:55 NEW MONTGOMERY ST
Practice Address - Street 2:SUITE 725
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94105-3412
Practice Address - Country:US
Practice Address - Phone:415-543-2418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY9507103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral