Provider Demographics
NPI:1962007369
Name:WALLEN, GRAYSON (LPCC)
Entity Type:Individual
Prefix:
First Name:GRAYSON
Middle Name:
Last Name:WALLEN
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 SAXONY RD STE 205
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-6780
Mailing Address - Country:US
Mailing Address - Phone:480-234-8363
Mailing Address - Fax:
Practice Address - Street 1:169 SAXONY RD STE 205
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-6780
Practice Address - Country:US
Practice Address - Phone:480-234-8363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5227101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional