Healthcare Provider Details

I. General information

NPI: 1396305116
Provider Name (Legal Business Name): LETHA GRAYSON PSY.D , LADAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2019
Last Update Date: 06/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43845 10TH ST W
LANCASTER CA
93534-4800
US

IV. Provider business mailing address

1900 E OCEAN BLVD APT 415
LONG BEACH CA
90802-6137
US

V. Phone/Fax

Practice location:
  • Phone: 661-402-1545
  • Fax: 661-727-0006
Mailing address:
  • Phone: 323-481-6554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberLR02501016
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: