Provider Demographics
NPI:1831780469
Name:GRAY-LEBLUE, VANESSA
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:GRAY-LEBLUE
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 1:7881 OTHEL WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95828-2038
Mailing Address - Country:US
Mailing Address - Phone:916-288-7497
Mailing Address - Fax:
Practice Address - Street 1:4343 WILLIAMSBOURGH DR
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-2006
Practice Address - Country:US
Practice Address - Phone:916-395-3552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-27
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)