Provider Demographics
NPI:1255933230
Name:GRAYSON, KIMBERLY DANIELLE
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DANIELLE
Last Name:GRAYSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17171 BOLSA CHICA ST APT 9
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92649-5126
Mailing Address - Country:US
Mailing Address - Phone:714-795-1411
Mailing Address - Fax:
Practice Address - Street 1:120 S STATE COLLEGE BLVD STE 150
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-5837
Practice Address - Country:US
Practice Address - Phone:714-577-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-13
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist