Healthcare Provider Details

I. General information

NPI: 1679616981
Provider Name (Legal Business Name): ROBERT MORRIS GRAY PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 08/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15644 POMERADO RD SUITE 305
POWAY CA
92064-2400
US

IV. Provider business mailing address

15644 POMERADO RD SUITE 305
POWAY CA
92064-2400
US

V. Phone/Fax

Practice location:
  • Phone: 858-693-3113
  • Fax: 858-312-8460
Mailing address:
  • Phone: 858-693-3113
  • Fax: 858-312-8460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY 20705
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: