Provider Demographics
NPI:1417538125
Name:GRAY, JOHNNIE RAY JR
Entity Type:Individual
Prefix:
First Name:JOHNNIE
Middle Name:RAY
Last Name:GRAY
Suffix:JR
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 1:11852 MOUNT VERNON AVE APT 605
Mailing Address - Street 2:
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-8317
Mailing Address - Country:US
Mailing Address - Phone:480-686-3388
Mailing Address - Fax:
Practice Address - Street 1:2085 RUSTIN AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-2498
Practice Address - Country:US
Practice Address - Phone:951-955-7161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-15
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health