Provider Demographics
NPI:1396305116
Name:GRAYSON, LETHA (PSYD , LADAC)
Entity type:Individual
Prefix:DR
First Name:LETHA
Middle Name:
Last Name:GRAYSON
Suffix:
Gender:F
Credentials:PSYD , LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 E OCEAN BLVD APT 415
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-6137
Mailing Address - Country:US
Mailing Address - Phone:323-481-6554
Mailing Address - Fax:
Practice Address - Street 1:43845 10TH ST W
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-4800
Practice Address - Country:US
Practice Address - Phone:661-402-1545
Practice Address - Fax:661-727-0006
Is Sole Proprietor?:No
Enumeration Date:2019-06-14
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LR02501016103TA0400X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)