Provider Demographics
NPI:1700256914
Name:GRAM, ALINA M (PSYD)
Entity Type:Individual
Prefix:
First Name:ALINA
Middle Name:M
Last Name:GRAM
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 NEWPORT CENTER DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7506
Mailing Address - Country:US
Mailing Address - Phone:714-497-3519
Mailing Address - Fax:
Practice Address - Street 1:220 NEWPORT CENTER DR
Practice Address - Street 2:SUITE 1
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7506
Practice Address - Country:US
Practice Address - Phone:714-497-3519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-30
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY26514103G00000X, 103TA0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging