Healthcare Provider Details

I. General information

NPI: 1790160182
Provider Name (Legal Business Name): GRAYSON JAMES LEWIS PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2015
Last Update Date: 02/11/2022
Certification Date: 03/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 S SUNWEST LN
SAN BERNARDINO CA
92408-3258
US

IV. Provider business mailing address

1305 TOMMYDON ST
STOCKTON CA
95210-3364
US

V. Phone/Fax

Practice location:
  • Phone: 909-252-4010
  • Fax:
Mailing address:
  • Phone: 209-476-3341
  • Fax: 209-476-3528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY32222
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: