Healthcare Provider Details

I. General information

NPI: 1881260636
Provider Name (Legal Business Name): MR. MICHAEL MARTIN GRAUSAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2021
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9749 COTTONWOOD WAY
ALTA LOMA CA
91737-2955
US

IV. Provider business mailing address

9749 COTTONWOOD WAY
ALTA LOMA CA
91737-2955
US

V. Phone/Fax

Practice location:
  • Phone: 909-241-0986
  • Fax:
Mailing address:
  • Phone: 909-241-0986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-24-74062
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: