Provider Demographics
NPI:1295469310
Name:GRAY, MICHELLE (LAC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23954 HAYNES ST
Mailing Address - Street 2:
Mailing Address - City:WEST HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91307-3156
Mailing Address - Country:US
Mailing Address - Phone:818-515-1145
Mailing Address - Fax:
Practice Address - Street 1:23133 VENTURA BLVD STE 103
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-1184
Practice Address - Country:US
Practice Address - Phone:818-642-7519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-14
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19437171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist