Basic Information
| Provider Information | |||||||||
| NPI: | 1740474220 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRIGSBY | ||||||||
| FirstName: | WAYNE | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CADAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1931 CENTER ST | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947041105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5106669552 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1931 CENTER ST | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947041105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5106669552 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2007 | ||||||||
| LastUpdateDate: | 08/25/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | I2011506 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 171 | 01 | CA | OTHER | OTHER |