Provider Demographics
NPI:1679995781
Name:GRAY, ANGELA THEXTON
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:THEXTON
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 1:218 E COMMONWEALTH AVE
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92832-1911
Mailing Address - Country:US
Mailing Address - Phone:714-992-4770
Mailing Address - Fax:714-992-5475
Practice Address - Street 1:218 E COMMONWEALTH AVE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832-1911
Practice Address - Country:US
Practice Address - Phone:714-992-4770
Practice Address - Fax:714-992-5475
Is Sole Proprietor?:No
Enumeration Date:2014-01-08
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10236101YA0400X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)