Healthcare Provider Details

I. General information

NPI: 1255040317
Provider Name (Legal Business Name): ANDREW ANTHONY GRAY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2022
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3707 E SHIELDS AVE
FRESNO CA
93726-7029
US

IV. Provider business mailing address

4031 W NOBLE AVE
VISALIA CA
93277-1631
US

V. Phone/Fax

Practice location:
  • Phone: 559-229-9041
  • Fax:
Mailing address:
  • Phone: 559-623-0101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number17356
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: