Provider Demographics
NPI:1194575019
Name:GRAY WHALE MARRIAGE AND FAMILY THERAPY PROF CORP
Entity type:Organization
Organization Name:GRAY WHALE MARRIAGE AND FAMILY THERAPY PROF CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:VICTORIA
Authorized Official - Last Name:BRUASKI
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:619-213-2470
Mailing Address - Street 1:PO BOX 231012
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92193-1012
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8426 FIRESIDE AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-2848
Practice Address - Country:US
Practice Address - Phone:714-337-4969
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty