Provider Demographics
NPI:1619246915
Name:GRAY, ROBERT BRUCE III
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:BRUCE
Last Name:GRAY
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1975 LONG BEACH BLVD.
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806
Mailing Address - Country:US
Mailing Address - Phone:626-664-0613
Mailing Address - Fax:
Practice Address - Street 1:1975 LONG BEACH BLVD
Practice Address - Street 2:#170
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-5501
Practice Address - Country:US
Practice Address - Phone:626-664-0613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-15
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32042101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health