Healthcare Provider Details

I. General information

NPI: 1982054755
Provider Name (Legal Business Name): JOHN GRAY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2016
Last Update Date: 05/01/2025
Certification Date: 05/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 EDMONDS RD BLDG D
REDWOOD CITY CA
94062-3813
US

IV. Provider business mailing address

240 EDMONDS RD BLDG D
REDWOOD CITY CA
94062-3813
US

V. Phone/Fax

Practice location:
  • Phone: 650-209-1100
  • Fax:
Mailing address:
  • Phone: 650-209-1100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License NumberPT31312
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: