Provider Demographics
NPI:1790160182
Name:LEWIS, GRAYSON JAMES (PSYD)
Entity Type:Individual
Prefix:
First Name:GRAYSON
Middle Name:JAMES
Last Name:LEWIS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 TOMMYDON ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-3364
Mailing Address - Country:US
Mailing Address - Phone:209-476-3341
Mailing Address - Fax:209-476-3528
Practice Address - Street 1:1950 S SUNWEST LN
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3258
Practice Address - Country:US
Practice Address - Phone:909-252-4010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-27
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAPSY32222103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program