Provider Demographics
NPI:1881260636
Name:GRAUSAM, MICHAEL MARTIN
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:MARTIN
Last Name:GRAUSAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9749 COTTONWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:ALTA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91737-2955
Mailing Address - Country:US
Mailing Address - Phone:909-241-0986
Mailing Address - Fax:
Practice Address - Street 1:9749 COTTONWOOD WAY
Practice Address - Street 2:
Practice Address - City:ALTA LOMA
Practice Address - State:CA
Practice Address - Zip Code:91737-2955
Practice Address - Country:US
Practice Address - Phone:909-241-0986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-02
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
CA1-24-74062103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician