1649328865 NPI number — DIANNA LYNNETTE GRAYER MA, MFT

Table of content: DIANNA LYNNETTE GRAYER MA, MFT (NPI 1649328865)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649328865 NPI number — DIANNA LYNNETTE GRAYER MA, MFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAYER
Provider First Name:
DIANNA
Provider Middle Name:
LYNNETTE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, MFT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649328865
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4340 ROBLAR RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PETALUMA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94952-9758
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-793-9840
Provider Business Mailing Address Fax Number:
707-793-9840

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7 4TH ST
Provider Second Line Business Practice Location Address:
SUITE 42
Provider Business Practice Location Address City Name:
PETALUMA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94952-3043
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-769-1853
Provider Business Practice Location Address Fax Number:
707-793-9840
Provider Enumeration Date:
01/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  33934 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: MFT 33934 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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