Healthcare Provider Details

I. General information

NPI: 1104330570
Provider Name (Legal Business Name): INTEGRATED PSYCHIATRY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2017
Last Update Date: 02/04/2020
Certification Date: 02/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25000 AVENUE STANFORD STE 173
VALENCIA CA
91355-4596
US

IV. Provider business mailing address

27943 SECO CANYON RD # 573
SANTA CLARITA CA
91350-3872
US

V. Phone/Fax

Practice location:
  • Phone: 818-927-0688
  • Fax: 818-888-5982
Mailing address:
  • Phone: 818-927-0688
  • Fax: 866-543-9915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberA111804
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084P0005X
TaxonomyNeurodevelopmental Disabilities Physician
License NumberA111804
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA111804
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberA111804
License Number StateCA

VIII. Authorized Official

Name: LOURDES GRAYSON
Title or Position: PRESIDENT
Credential: MD
Phone: 818-927-0688