Healthcare Provider Details

I. General information

NPI: 1619832524
Provider Name (Legal Business Name): NICKI GRAY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2025
Last Update Date: 12/23/2025
Certification Date: 12/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S MAIN ST STE 600
ORANGE CA
92868-4514
US

IV. Provider business mailing address

307 S SMITH AVE TRLR 64
CORONA CA
92882-1744
US

V. Phone/Fax

Practice location:
  • Phone: 714-595-7795
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: