Healthcare Provider Details

I. General information

NPI: 1861422495
Provider Name (Legal Business Name): GARY CHARLES GRAY LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1681 N STARR DR
FAYETTEVILLE AR
72701-2936
US

IV. Provider business mailing address

1681 N STARR DR
FAYETTEVILLE AR
72701-2936
US

V. Phone/Fax

Practice location:
  • Phone: 479-442-4958
  • Fax:
Mailing address:
  • Phone: 479-442-4958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberC486
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: