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General NPI Number Information
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NPI Number | 1346350378
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Entity Type | Individual
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Provider Name | JONATHAN BRUCE GRAYSON PH.D.
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Gender | Male
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Dates
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Enumeration Date | 08/31/2006
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Last Update Date | 10/20/2021
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Provider Practice Location Address
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Address Line | 4 E HOLLY ST STE 219
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City | PASADENA
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State | CA
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Zip | 91103-4519
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Country | US
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Telephone | 626-639-3994
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Fax |
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Provider Business Mailing Address
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Address Line | 155 CORDOVA ST UNIT 304
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City | PASADENA
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State | CA
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Zip | 91105-2749
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Country | US
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Telephone | 610-416-0122
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | PS003671L
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License Number State | PA
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