MEDICARE: ALICIA J GRAY M.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	200936750 A	OTHER	IN	WAIVER-32 CAPRT-F GRANT

General Provider Information

NPI Number	:	1508009887
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALICIA J GRAY M.A.

Provider Business Mailing Address
First Line	:	3151 STILLMEADOW DR
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46214-1529
Country	:	US
Telephone Number	:	317-294-5454
Fax Number	:	317-295-1713

Provider Business Practice Location Address
First Line	:	3151 STILLMEADOW DR
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46214-1529
Country	:	US
Telephone Number	:	317-294-5454
Fax Number	:	317-295-1713

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/15/2009
Last Update Date	:	05/17/2010

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