Basic Information
Provider Information
NPI: 1033557111
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: GRAY
FirstName: HENRY
MiddleName: R.
NamePrefix: MR.
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 531 N HOLLYWOOD WAY # A266
Address2:  
City: BURBANK
State: CA
PostalCode: 915054977
CountryCode: US
TelephoneNumber: 8186939052
FaxNumber:  
Practice Location
Address1: 503 OCEAN FRONT WALK
Address2:  
City: VENICE
State: CA
PostalCode: 902912403
CountryCode: US
TelephoneNumber: 3103923070
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/11/2013
LastUpdateDate: 12/04/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YA0400X  Y Behavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)

No ID Information.


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