MEDICARE: DR. KELLEN R GRAYSON PSY.D. LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	50074	CA

General Provider Information

NPI Number	:	1912119934
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLEN R GRAYSON PSY.D. LMFT

Provider Business Mailing Address
First Line	:	4070 BRIDGE ST STE 3
Second Line	:
City	:	FAIR OAKS
State	:	CA
Zip	:	95628-7557
Country	:	US
Telephone Number	:	415-320-0141
Fax Number	:	916-357-9111

Provider Business Practice Location Address
First Line	:	4070 BRIDGE ST STE 3
Second Line	:
City	:	FAIR OAKS
State	:	CA
Zip	:	95628-7557
Country	:	US
Telephone Number	:	415-320-0141
Fax Number	:	510-201-2491

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	05/23/2025

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