MEDICARE: MR. COLBY EARL GRAY BA

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	101YM0800X	Mental Health Counselor
2	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1457663502
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. COLBY EARL GRAY BA

Provider Business Mailing Address
First Line	:	470 E 3RD ST
Second Line	:	SUITE C
City	:	LOS ANGELES
State	:	CA
Zip	:	90013-1629
Country	:	US
Telephone Number	:	213-620-5712
Fax Number	:

Provider Business Practice Location Address
First Line	:	470 E 3RD ST
Second Line	:	SUITE C
City	:	LOS ANGELES
State	:	CA
Zip	:	90013-1629
Country	:	US
Telephone Number	:	213-620-5712
Fax Number	:

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

Provider Enumeration Date	:	07/06/2010
Last Update Date	:	11/30/2015

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