Provider Demographics
NPI:1306123567
Name:GRAY, ANGELA M (CADCA)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:M
Last Name:GRAY
Suffix:
Gender:F
Credentials:CADCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:443 E AMERIGE AVE
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92832-2005
Mailing Address - Country:US
Mailing Address - Phone:714-624-0989
Mailing Address - Fax:
Practice Address - Street 1:321 N STATE COLLEGE BLVD
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92806-2915
Practice Address - Country:US
Practice Address - Phone:714-687-0077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-15
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13861210101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)