Healthcare Provider Details

I. General information

NPI: 1245933019
Provider Name (Legal Business Name): NICOLE LORRAINE GRAY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2023
Last Update Date: 03/14/2024
Certification Date: 03/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3767 CENTRAL AVE
SAN DIEGO CA
92105-2599
US

IV. Provider business mailing address

3767 CENTRAL AVE
SAN DIEGO CA
92105-2599
US

V. Phone/Fax

Practice location:
  • Phone: 619-584-4010
  • Fax: 619-278-0770
Mailing address:
  • Phone: 619-584-4010
  • Fax: 619-278-0770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: