Provider Demographics
NPI:1245572304
Name:RAY, DEREK B
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:B
Last Name:RAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1031 25TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-2102
Mailing Address - Country:US
Mailing Address - Phone:619-232-6454
Mailing Address - Fax:
Practice Address - Street 1:5348 UNIVERSITY AVE
Practice Address - Street 2:#101
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-8025
Practice Address - Country:US
Practice Address - Phone:619-229-2999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-26
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health