Healthcare Provider Details

I. General information

NPI: 1437036498
Provider Name (Legal Business Name): STEFANIE GRAY
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2025
Last Update Date: 08/20/2025
Certification Date: 08/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

891 MOUNTAIN RANCH RD
SAN ANDREAS CA
95249-9713
US

IV. Provider business mailing address

6864 HARDING RD
VALLEY SPRINGS CA
95252-8759
US

V. Phone/Fax

Practice location:
  • Phone: 209-754-6525
  • Fax:
Mailing address:
  • Phone: 209-256-1933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: