1619325388 NPI number — SHANEQUA GRAY LLMSW

Table of content: SHANEQUA GRAY LLMSW (NPI 1619325388)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619325388 NPI number — SHANEQUA GRAY LLMSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAY
Provider First Name:
SHANEQUA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LLMSW
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:
1619325388
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/20/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
315 W DEWEY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLINT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48505-4001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-802-1834
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17456 KINGSBROOKE CIR
Provider Second Line Business Practice Location Address:
APT 102
Provider Business Practice Location Address City Name:
CLINTON TOWNSHIP
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48038-3769
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-846-6004
Provider Business Practice Location Address Fax Number:
844-280-3924
Provider Enumeration Date:
06/02/2016

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: 104100000X , with the licence number:  6801098492 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 6801098492 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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