Provider Demographics
NPI:1598220626
Name:GRAY-RENEBERG, WREN (MA)
Entity Type:Individual
Prefix:
First Name:WREN
Middle Name:
Last Name:GRAY-RENEBERG
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1957 PRUNERIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95050-6515
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1957 PRUNERIDGE AVE
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95050-6515
Practice Address - Country:US
Practice Address - Phone:805-506-9683
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-02
Last Update Date:2019-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA109983106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist