Provider Demographics
NPI:1396016903
Name:GRAY, KANDICE DOMINIQUE
Entity Type:Individual
Prefix:
First Name:KANDICE
Middle Name:DOMINIQUE
Last Name:GRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1777 N BELLFLOWER BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90815-4019
Mailing Address - Country:US
Mailing Address - Phone:323-402-1803
Mailing Address - Fax:
Practice Address - Street 1:1777 N BELLFLOWER BLVD STE 105
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90815-4019
Practice Address - Country:US
Practice Address - Phone:323-402-1803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-13
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW900951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical