Healthcare Provider Details

I. General information

NPI: 1932733698
Provider Name (Legal Business Name): SEAN GRAY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2020
Last Update Date: 12/15/2021
Certification Date: 12/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19401 S VERMONT AVE # L-102
TORRANCE CA
90502-1029
US

IV. Provider business mailing address

19401 S VERMONT AVE # L-102
TORRANCE CA
90502-1029
US

V. Phone/Fax

Practice location:
  • Phone: 310-323-6887
  • Fax:
Mailing address:
  • Phone: 310-323-6887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1329091118
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number129903
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: