Basic Information
| Provider Information | |||||||||
| NPI: | 1821374620 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAY | ||||||||
| FirstName: | MONIQUE | ||||||||
| MiddleName: | D'LISA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6666 GREEN VALLEY CIR | ||||||||
| Address2: | |||||||||
| City: | CULVER CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902307068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108465270 | ||||||||
| FaxNumber: | 3108465278 | ||||||||
| Practice Location | |||||||||
| Address1: | 6666 GREEN VALLEY CIR | ||||||||
| Address2: | |||||||||
| City: | CULVER CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902307068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108465270 | ||||||||
| FaxNumber: | 3108465278 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2011 | ||||||||
| LastUpdateDate: | 08/30/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 225700000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist | 225700000X | 82712 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
No ID Information.