1003068529 NPI number — DR. GENEVA MARIE GRAY PHD, LPC, NCC, CPCS

Table of content: DR. GENEVA MARIE GRAY PHD, LPC, NCC, CPCS (NPI 1003068529)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003068529 NPI number — DR. GENEVA MARIE GRAY PHD, LPC, NCC, CPCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAY
Provider First Name:
GENEVA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD, LPC, NCC, CPCS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003068529
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2330 SCENIC HWY S
Provider Second Line Business Mailing Address:
SUITE 115
Provider Business Mailing Address City Name:
SNELLVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30078-3115
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-559-9919
Provider Business Mailing Address Fax Number:
404-891-5095

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2330 SCENIC HWY S
Provider Second Line Business Practice Location Address:
SUITE 115
Provider Business Practice Location Address City Name:
SNELLVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30078-3115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-559-9919
Provider Business Practice Location Address Fax Number:
404-891-5095
Provider Enumeration Date:
10/15/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , with the licence number:  0004236 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 922721756B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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