Healthcare Provider Details

I. General information

NPI: 1376002519
Provider Name (Legal Business Name): GRAYSON AIKO LIEBES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2019
Last Update Date: 07/27/2023
Certification Date: 07/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3731 6TH AVE STE 100
SAN DIEGO CA
92103-4383
US

IV. Provider business mailing address

8030 LA MESA BLVD STE 25
LA MESA CA
91942-0335
US

V. Phone/Fax

Practice location:
  • Phone: 855-223-7123
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-23-66935
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-19-81350
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: