=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225924947
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRAIN WAVE PSYCHIATRY, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2025
-----------------------------------------------------
Last Update Date | 10/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8605 SANTA MONICA BLVD PMB 326031
-----------------------------------------------------
City | WEST HOLLYWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90069-4109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-571-9838
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4403 EDAM ST
-----------------------------------------------------
City | LANCASTER
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93536-6875
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-571-9838
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | GREGORY DESIR
-----------------------------------------------------
Credential | PMHNP-BC
-----------------------------------------------------
Telephone | 661-571-9838
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------