Provider Demographics
NPI:1871940502
Name:GRAY, CYNTHIA ANN (CADC-II, ICADC)
Entity type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:ANN
Last Name:GRAY
Suffix:
Gender:F
Credentials:CADC-II, ICADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:628 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:BANNING
Mailing Address - State:CA
Mailing Address - Zip Code:92220-4512
Mailing Address - Country:US
Mailing Address - Phone:951-849-9491
Mailing Address - Fax:951-849-8262
Practice Address - Street 1:628 S 8TH ST
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-4512
Practice Address - Country:US
Practice Address - Phone:951-849-9491
Practice Address - Fax:951-849-8262
Is Sole Proprietor?:No
Enumeration Date:2016-05-23
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA020400815101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA02575712Medicare PIN