Provider Demographics
NPI:1598220626
Name:ST. GRAY, WREN (MA)
Entity type:Individual
Prefix:
First Name:WREN
Middle Name:
Last Name:ST. GRAY
Suffix:
Gender:
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1776
Mailing Address - Street 2:
Mailing Address - City:DISCOVERY BAY
Mailing Address - State:CA
Mailing Address - Zip Code:94505-7776
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1415 N OAKES ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98406-7416
Practice Address - Country:US
Practice Address - Phone:805-506-9683
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-02
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALF61355544106H00000X
CA132834106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist