Provider Demographics
NPI:1114770088
Name:GRAY, JOSEPH (PEER SUPPORT SPECIAL)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:GRAY
Suffix:
Gender:M
Credentials:PEER SUPPORT SPECIAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3939 MADISON AVE APT 256
Mailing Address - Street 2:
Mailing Address - City:NORTH HIGHLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:95660-6319
Mailing Address - Country:US
Mailing Address - Phone:530-908-1507
Mailing Address - Fax:
Practice Address - Street 1:215 W BEAMER ST
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-2510
Practice Address - Country:US
Practice Address - Phone:530-759-3136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-09
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMPSS-NIDMLU175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist