Provider Demographics
NPI:1578279899
Name:GRAY, BRANDAN DEAN (STUDENT)
Entity Type:Individual
Prefix:
First Name:BRANDAN
Middle Name:DEAN
Last Name:GRAY
Suffix:
Gender:M
Credentials:STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 W 9TH PL
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:CA
Mailing Address - Zip Code:92223-1653
Mailing Address - Country:US
Mailing Address - Phone:909-800-5198
Mailing Address - Fax:
Practice Address - Street 1:940 E WILLIAMS ST STE 102
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-5848
Practice Address - Country:US
Practice Address - Phone:951-588-2553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-30
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA1198381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program