Healthcare Provider Details

I. General information

NPI: 1477648707
Provider Name (Legal Business Name): JAMES MICHAEL GRESHAM MHP, RASI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 W 5TH ST STE 212
SANTA ANA CA
92701-4522
US

IV. Provider business mailing address

2960 CHAMPION WAY APT 2608
TUSTIN CA
92782-1213
US

V. Phone/Fax

Practice location:
  • Phone: 714-834-2125
  • Fax:
Mailing address:
  • Phone: 714-225-9636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: