Provider Demographics
NPI:1821374620
Name:GRAY, MONIQUE D'LISA
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:D'LISA
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 1:6666 GREEN VALLEY CIR
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-7068
Mailing Address - Country:US
Mailing Address - Phone:310-846-5270
Mailing Address - Fax:310-846-5278
Practice Address - Street 1:6666 GREEN VALLEY CIR
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-7068
Practice Address - Country:US
Practice Address - Phone:310-846-5270
Practice Address - Fax:310-846-5278
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-25
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 225700000X
CA82712225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health