Provider Demographics
NPI:1558879585
Name:GRAY, CORI
Entity Type:Individual
Prefix:
First Name:CORI
Middle Name:
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 1:2400 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-2802
Mailing Address - Country:US
Mailing Address - Phone:530-241-0552
Mailing Address - Fax:
Practice Address - Street 1:2400 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-2802
Practice Address - Country:US
Practice Address - Phone:530-241-0552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-11
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60909749101YA0400X
WA106S00000X
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician