Provider Demographics
NPI:1629448048
Name:CHANEY-GAY, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:CHANEY-GAY
Suffix:
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 1:837 N WEST KNOLL DR APT 118
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90069-4723
Mailing Address - Country:US
Mailing Address - Phone:740-586-3157
Mailing Address - Fax:
Practice Address - Street 1:837 N WEST KNOLL DR APT 118
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90069-4723
Practice Address - Country:US
Practice Address - Phone:740-586-3157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-28
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA1037991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program