1932262235 NPI number — JULIE BETH GRAY LCSW

Table of content: CAROLINE SULLIVAN LPC (NPI 1275140048)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932262235 NPI number — JULIE BETH GRAY LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAY
Provider First Name:
JULIE
Provider Middle Name:
BETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
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:
1932262235
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/12/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
107 TOALNE RD
Provider Second Line Business Mailing Address:
UNIT # 3
Provider Business Mailing Address City Name:
TAOS
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87571-5253
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-770-1880
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1337 GUSDORF ROAD
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
TAOS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87571
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-758-4297
Provider Business Practice Location Address Fax Number:
575-751-7237
Provider Enumeration Date:
12/18/2006

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: 1041S0200X , with the licence number:  M-06154 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: M-06154 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 26523779 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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