Provider Demographics
NPI:1255350310
Name:RALEY, GARRY LEE (MFT)
Entity type:Individual
Prefix:
First Name:GARRY
Middle Name:LEE
Last Name:RALEY
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 51591
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92517-2591
Mailing Address - Country:US
Mailing Address - Phone:951-640-5899
Mailing Address - Fax:
Practice Address - Street 1:7965 SIERRA AVE
Practice Address - Street 2:SUITE J
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-3329
Practice Address - Country:US
Practice Address - Phone:909-355-3888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 28670106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist