Provider Demographics
NPI:1548550122
Name:GRIESHABER, MARK (MFT)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:GRIESHABER
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10379 W PICO BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-2608
Mailing Address - Country:US
Mailing Address - Phone:310-551-1829
Mailing Address - Fax:
Practice Address - Street 1:10379 W PICO BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-2608
Practice Address - Country:US
Practice Address - Phone:310-785-9456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-15
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC36016106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist