Provider Demographics
NPI:1720268980
Name:INTEGRATIVE PSYCHIATRY A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:INTEGRATIVE PSYCHIATRY A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:GRIGOR
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIGORYAN
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:949-309-7903
Mailing Address - Street 1:29982 IVY GLENN DR
Mailing Address - Street 2:#203
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677
Mailing Address - Country:US
Mailing Address - Phone:949-309-7903
Mailing Address - Fax:949-716-5243
Practice Address - Street 1:29982 IVY GLENN DR
Practice Address - Street 2:#203
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677
Practice Address - Country:US
Practice Address - Phone:949-309-7903
Practice Address - Fax:949-716-5243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-05
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA775921106H00000X
106H00000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA64M841Medicare PIN
CAG87276Medicare UPIN