=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902106370
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEIDI E. GRAY LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2010
-----------------------------------------------------
Last Update Date | 03/03/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1829 MARKET ST STE 202
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94103-7414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-906-3939
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1733 H. STREET STUDIO 450 #588
-----------------------------------------------------
City | BLAINE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98230-7414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 159-063-9394
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | LMFT84787
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | INTERN #63600
-----------------------------------------------------
License Number State |
-----------------------------------------------------