Healthcare Provider Details

I. General information

NPI: 1639944267
Provider Name (Legal Business Name): MR. GARY RICARDO GRAY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2023
Last Update Date: 06/02/2025
Certification Date: 06/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 EUCLID ST W
HARTFORD CT
06112-1118
US

IV. Provider business mailing address

14 ELRO ST
MANCHESTER CT
06040-4228
US

V. Phone/Fax

Practice location:
  • Phone: 860-478-6584
  • Fax:
Mailing address:
  • Phone: 860-478-6584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11100
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: