Provider Demographics
NPI:1407045719
Name:GRAY, SUSAN LOUISE (LVN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LOUISE
Last Name:GRAY
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SAN JACINTO
Mailing Address - State:CA
Mailing Address - Zip Code:92583-4121
Mailing Address - Country:US
Mailing Address - Phone:951-487-8376
Mailing Address - Fax:951-487-8458
Practice Address - Street 1:102 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92583-4121
Practice Address - Country:US
Practice Address - Phone:951-487-8376
Practice Address - Fax:951-487-8458
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-23
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN149539101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health