Provider Demographics
NPI:1962014431
Name:MCVAY, TRAYVONNE
Entity Type:Individual
Prefix:
First Name:TRAYVONNE
Middle Name:
Last Name:MCVAY
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 1:5550 WILSHIRE BLVD APT 235
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-4857
Mailing Address - Country:US
Mailing Address - Phone:818-438-6754
Mailing Address - Fax:
Practice Address - Street 1:624 W 9TH ST STE 103
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-3158
Practice Address - Country:US
Practice Address - Phone:818-438-6754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-17
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSB94024918103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical