Provider Demographics
NPI:1699155622
Name:HAYMON, GREGORY
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:HAYMON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 EAST VERDUGO AVE #103
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:95102
Mailing Address - Country:US
Mailing Address - Phone:310-701-3109
Mailing Address - Fax:
Practice Address - Street 1:301 E VERDUGO AVE APT 103
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91502-2917
Practice Address - Country:US
Practice Address - Phone:310-701-3109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-04
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA243051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical