| Doctor Name: | CHANNING GREDVIG |
| NPI Number: | 1003113622 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | LCSW |
| License Number: | 64651 |
| Business Practice Address: | 3420 Kenyon St San Diego, CA - 921105001 |
| Business Phone Number: | 6192216550 |
| Business Fax Number: | 6192216556 |
| Mailing Address: | 3420 Kenyon St, SAN DIEGO |
| State: | CA |
| Postal Code: | 921105001 |
| Phone Number: | 6192216550 |
| Fax Number: | 6192216556 |
| NPI Enumeration Date: | 02/16/2011 |
| NPI Last Update Date: | 06/26/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1041C0700X |
| License Number: | 64651 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | CA |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Social Worker |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | A social worker who holds a master |