Basic Information
Provider Information | |||||||||
NPI: | 1528464534 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GRAY | ||||||||
FirstName: | EMILY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 652 FOREST AVE | ||||||||
Address2: |   | ||||||||
City: | PALO ALTO | ||||||||
State: | CA | ||||||||
PostalCode: | 943012622 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6503231401 | ||||||||
FaxNumber: | 6503231720 | ||||||||
Practice Location | |||||||||
Address1: | 652 FOREST AVE | ||||||||
Address2: |   | ||||||||
City: | PALO ALTO | ||||||||
State: | CA | ||||||||
PostalCode: | 943012622 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6503231401 | ||||||||
FaxNumber: | 6503231720 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/18/2014 | ||||||||
LastUpdateDate: | 03/17/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X |   |   | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 106H00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 1881813350 | 05 | CA |   | MEDICAID |