Provider Demographics
NPI:1992228852
Name:GRAY, LISA MICHELLE (MA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MICHELLE
Last Name:GRAY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:691 MCLEOD ST
Mailing Address - Street 2:
Mailing Address - City:LIVERMORE
Mailing Address - State:CA
Mailing Address - Zip Code:94550-4763
Mailing Address - Country:US
Mailing Address - Phone:925-784-0415
Mailing Address - Fax:
Practice Address - Street 1:1062 MURRIETA BLVD
Practice Address - Street 2:
Practice Address - City:LIVERMORE
Practice Address - State:CA
Practice Address - Zip Code:94550-4111
Practice Address - Country:US
Practice Address - Phone:925-784-0415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-24
Last Update Date:2018-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44983106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist