Healthcare Provider Details

I. General information

NPI: 1134296601
Provider Name (Legal Business Name): CHARLES MCCRAY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MARGUERITE MCCRAY

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8225 W TUCKEY LN
GLENDALE AZ
85303-3210
US

IV. Provider business mailing address

8225 W TUCKEY LN
GLENDALE AZ
85303-3210
US

V. Phone/Fax

Practice location:
  • Phone: 623-463-1936
  • Fax:
Mailing address:
  • Phone: 623-463-1936
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number9094
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: