Provider Demographics
NPI:1346806395
Name:GRAY, CYNTHIA DIANE (LCSW)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:DIANE
Last Name:GRAY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:CYNTHIA
Other - Middle Name:
Other - Last Name:BACON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:940 DISC DR
Mailing Address - Street 2:
Mailing Address - City:SCOTTS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95066-4544
Mailing Address - Country:US
Mailing Address - Phone:831-430-3039
Mailing Address - Fax:
Practice Address - Street 1:127 LADERA DR
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-5210
Practice Address - Country:US
Practice Address - Phone:831-234-1294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-15
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA66377101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty