Healthcare Provider Details

I. General information

NPI: 1003783705
Provider Name (Legal Business Name): GREGORY KENT DORRIS
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2025
Last Update Date: 10/20/2025
Certification Date: 10/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 S ORANGE GROVE BLVD
PASADENA CA
91105-1705
US

IV. Provider business mailing address

4620A HOLLYWOOD BLVD
LOS ANGELES CA
90027-5408
US

V. Phone/Fax

Practice location:
  • Phone: 626-678-0927
  • Fax:
Mailing address:
  • Phone: 626-678-0927
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number19505
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number155197
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: