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General NPI Number Information
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NPI Number | 1912119934
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Entity Type | Individual
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Provider Name | KELLEN R GRAYSON PSY.D. LMFT
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Gender | Male
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Dates
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Enumeration Date | 05/03/2007
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Last Update Date | 05/23/2025
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Provider Practice Location Address
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Address Line | 4070 BRIDGE ST STE 3
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City | FAIR OAKS
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State | CA
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Zip | 95628-7557
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Country | US
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Telephone | 415-320-0141
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Fax | 510-201-2491
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Provider Business Mailing Address
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Address Line | 4070 BRIDGE ST STE 3
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City | FAIR OAKS
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State | CA
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Zip | 95628-7557
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Country | US
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Telephone | 415-320-0141
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Fax | 916-357-9111
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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 | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 50074
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License Number State | CA
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