Healthcare Provider Details

I. General information

NPI: 1114770088
Provider Name (Legal Business Name): JOSEPH GRAY PEER SUPPORT SPECIAL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2024
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 W BEAMER ST
WOODLAND CA
95695-2510
US

IV. Provider business mailing address

3939 MADISON AVE APT 256
NORTH HIGHLANDS CA
95660-6319
US

V. Phone/Fax

Practice location:
  • Phone: 530-759-3136
  • Fax:
Mailing address:
  • Phone: 530-908-1507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberRT1449140726
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-NIDMLU
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: