MEDICARE: BONNIE LEE GRAY PH.D.

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	103T00000X	Psychologist	LP1053	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	43184GR	OTHER	MN	BLUE CROSS BLUE SHIELD
3	104210	OTHER	MN	UCARE

General Provider Information

NPI Number	:	1710926050
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BONNIE LEE GRAY PH.D.

Provider Business Mailing Address
First Line	:	241 CLEVELAND AVE S
Second Line	:	SUITE P
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-1208
Country	:	US
Telephone Number	:	651-690-3808
Fax Number	:

Provider Business Practice Location Address
First Line	:	241 CLEVELAND AVE S
Second Line	:	SUITE P
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-1208
Country	:	US
Telephone Number	:	651-690-3808
Fax Number	:

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

Provider Enumeration Date	:	06/05/2006
Last Update Date	:	11/27/2012

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