Healthcare Provider Details

I. General information

NPI: 1689897068
Provider Name (Legal Business Name): DWIGHT H. GRISHAM M.A.,ED.S., ED.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 NEW MONTGOMERY ST SUITE 725
SAN FRANCISCO CA
94105-3412
US

IV. Provider business mailing address

55 NEW MONTGOMERY ST SUITE 725
SAN FRANCISCO CA
94105-3412
US

V. Phone/Fax

Practice location:
  • Phone: 415-543-2418
  • Fax:
Mailing address:
  • Phone: 415-543-2418
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPSY9507
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: