Healthcare Provider Details

I. General information

NPI: 1114428497
Provider Name (Legal Business Name): ELAINA GRAY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2018
Last Update Date: 02/17/2021
Certification Date: 02/02/2021
Deactivation Date: 08/18/2020
Reactivation Date: 09/16/2020

III. Provider practice location address

333 UNIVERSITY AVE STE 200
SACRAMENTO CA
95825-6540
US

IV. Provider business mailing address

3425 COFFEE RD STE C2
MODESTO CA
95355-1582
US

V. Phone/Fax

Practice location:
  • Phone: 855-832-6727
  • Fax: 772-675-9100
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-18-31531
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: