MEDICARE: KANDICE DOMINIQUE GRAY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LCSW90095	CA

General Provider Information

NPI Number	:	1396016903
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KANDICE DOMINIQUE GRAY

Provider Business Mailing Address
First Line	:	1777 N BELLFLOWER BLVD STE 105
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90815-4019
Country	:	US
Telephone Number	:	323-402-1803
Fax Number	:

Provider Business Practice Location Address
First Line	:	1777 N BELLFLOWER BLVD STE 105
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90815-4019
Country	:	US
Telephone Number	:	323-402-1803
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/13/2012
Last Update Date	:	09/01/2022

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Directions to “ KANDICE DOMINIQUE GRAY ” Practice Location

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