Healthcare Provider Details

I. General information

NPI: 1386118701
Provider Name (Legal Business Name): MATTHEW GRAYBERG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2019
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2368 MARITIME DR
ELK GROVE CA
95758-3652
US

IV. Provider business mailing address

2368 MARITIME DR
ELK GROVE CA
95758-3652
US

V. Phone/Fax

Practice location:
  • Phone: 916-580-1100
  • Fax:
Mailing address:
  • Phone: 916-580-1100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: