Provider Demographics
NPI:1851523955
Name:GRAYSON, LOURDES
Entity type:Individual
Prefix:DR
First Name:LOURDES
Middle Name:
Last Name:GRAYSON
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:LOURDES
Other - Middle Name:D
Other - Last Name:VILLARUZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1040 FLYNN RD
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-5092
Mailing Address - Country:US
Mailing Address - Phone:805-673-3930
Mailing Address - Fax:
Practice Address - Street 1:200 S WELLS RD STE 250
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93004-1383
Practice Address - Country:US
Practice Address - Phone:805-647-0991
Practice Address - Fax:805-647-7163
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-23
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY254459-12084P0800X
CAA1118042084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty