Provider Demographics
NPI:1790822294
Name:GRAY, CAROL LYNN (LMFT)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:LYNN
Last Name:GRAY
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2604 GLEN ECHO LN
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-8390
Mailing Address - Country:US
Mailing Address - Phone:559-901-8037
Mailing Address - Fax:559-684-1152
Practice Address - Street 1:2604 GLEN ECHO LN
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-8390
Practice Address - Country:US
Practice Address - Phone:559-901-8037
Practice Address - Fax:559-684-1152
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC42255106H00000X
CALMFT42255106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist