Provider Demographics
NPI:1568274207
Name:GRAY, CALLIE (LMT)
Entity type:Individual
Prefix:
First Name:CALLIE
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1483 MORENO DR
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-3152
Mailing Address - Country:US
Mailing Address - Phone:805-304-0592
Mailing Address - Fax:
Practice Address - Street 1:1720 E LOS ANGELES AVE STE 220
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-5819
Practice Address - Country:US
Practice Address - Phone:805-304-0592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-21
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA93216225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist