Basic Information
Provider Information | |||||||||
NPI: | 1952567695 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GRAY | ||||||||
FirstName: | CYNTHIA | ||||||||
MiddleName: | ELIZABETH | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SKINNER | ||||||||
OtherFirstName: | CYNTHIA | ||||||||
OtherMiddleName: | ELIZABETH | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 470 CHADBOURNE RD STE F | ||||||||
Address2: |   | ||||||||
City: | FAIRFIELD | ||||||||
State: | CA | ||||||||
PostalCode: | 945349600 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7075574560 | ||||||||
FaxNumber: | 7075577909 | ||||||||
Practice Location | |||||||||
Address1: | 470 CHADBOURNE RD STE F | ||||||||
Address2: |   | ||||||||
City: | FAIRFIELD | ||||||||
State: | CA | ||||||||
PostalCode: | 945349600 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7075574560 | ||||||||
FaxNumber: | 7075577909 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/01/2008 | ||||||||
LastUpdateDate: | 11/23/2011 | ||||||||
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 | 1041C0700X | 27747 | CA | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.