Basic Information
| Provider Information | |||||||||
| NPI: | 1538315569 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAY | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | |||||||||
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| Credential: | LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6424 N. 9TH STREET | ||||||||
| Address2: | CHILD & FAMILY GUIDANCE CENTER | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535654484 | ||||||||
| FaxNumber: | 2535655823 | ||||||||
| Practice Location | |||||||||
| Address1: | 6424 N. 9TH STREET | ||||||||
| Address2: | CHILD & FAMILY GUIDANCE CENTER | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535654484 | ||||||||
| FaxNumber: | 2535655823 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2008 | ||||||||
| LastUpdateDate: | 08/13/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | LF60007032 | WA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 101YM0800X | LF60007032 | WA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 910598103 | 01 | WA | TAX IDENTIFICATION NUMBER | OTHER |