Provider Demographics
NPI:1740709799
Name:GREAVES, BRYSON (PHD, LMFT)
Entity type:Individual
Prefix:DR
First Name:BRYSON
Middle Name:
Last Name:GREAVES
Suffix:
Gender:M
Credentials:PHD, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4025 GRESHAM ST UNIT 4
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-5865
Mailing Address - Country:US
Mailing Address - Phone:619-417-5166
Mailing Address - Fax:
Practice Address - Street 1:7946 IVANHOE AVE STE 203
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-4517
Practice Address - Country:US
Practice Address - Phone:619-417-5166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-11
Last Update Date:2017-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT98263106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist