Provider Demographics
NPI:1093921132
Name:GRAY, STEPHEN A (MFT)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:A
Last Name:GRAY
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 1:1227 LYNDHURST DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-0604
Mailing Address - Country:US
Mailing Address - Phone:951-683-1769
Mailing Address - Fax:
Practice Address - Street 1:5015 CANYON CREST DR
Practice Address - Street 2:SUITE 112
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-6000
Practice Address - Country:US
Practice Address - Phone:951-781-0510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC23324106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist