Provider Demographics
NPI:1891206967
Name:REAY, ROSS GORDON (CADC-II)
Entity Type:Individual
Prefix:
First Name:ROSS
Middle Name:GORDON
Last Name:REAY
Suffix:
Gender:M
Credentials:CADC-II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 BURCHETT ST APT 112
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-1314
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3323 MARENGO AVE
Practice Address - Street 2:
Practice Address - City:ALTADENA
Practice Address - State:CA
Practice Address - Zip Code:91001-4039
Practice Address - Country:US
Practice Address - Phone:626-765-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-17
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA044030317101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)