Healthcare Provider Details

I. General information

NPI: 1437993201
Provider Name (Legal Business Name): ERICA LIZETH GRAY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ERICA LIZETH ORELLANA

II. Dates (important events)

Enumeration Date: 06/25/2024
Last Update Date: 06/27/2024
Certification Date: 06/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24112 A ST
BEALE AFB CA
95903-1713
US

IV. Provider business mailing address

500 COTTON GIN LN
LAWRENCEVILLE GA
30045-8129
US

V. Phone/Fax

Practice location:
  • Phone: 530-634-2953
  • Fax:
Mailing address:
  • Phone: 770-369-2875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-2024-0399
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: