Provider Demographics
NPI:1982063020
Name:GRAY, WENDY (PHD)
Entity Type:Individual
Prefix:DR
First Name:WENDY
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 S IMPERIAL HWY
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92807-3943
Mailing Address - Country:US
Mailing Address - Phone:714-485-5938
Mailing Address - Fax:
Practice Address - Street 1:136 S IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92807-3943
Practice Address - Country:US
Practice Address - Phone:714-485-5938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-17
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30329103T00000X, 103TC2200X
103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA30329OtherPSYCHOLOGY LICENSE