MEDICARE: MR. GLENN EDWARD GRAY JR. LCSW

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	1041C0700X	Clinical Social Worker	11478	TX

General Provider Information

NPI Number	:	1992938146
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GLENN EDWARD GRAY JR. LCSW

Provider Business Mailing Address
First Line	:	539 HC 2122 W
Second Line	:
City	:	AQUILLA
State	:	TX
Zip	:	76622-2495
Country	:	US
Telephone Number	:	254-205-0993
Fax Number	:

Provider Business Practice Location Address
First Line	:	539 HC 2122 W
Second Line	:
City	:	AQUILLA
State	:	TX
Zip	:	76622-2495
Country	:	US
Telephone Number	:	254-205-0993
Fax Number	:

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

Provider Enumeration Date	:	09/03/2009
Last Update Date	:	09/03/2009

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