Healthcare Provider Details

I. General information

NPI: 1053646794
Provider Name (Legal Business Name): EKWENZI GRAY PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2009
Last Update Date: 08/08/2022
Certification Date: 08/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 COLLEGE STREET NW
WASHINGTON DC
20060-1810
US

IV. Provider business mailing address

12138 CENTRAL AVE STE 176
MITCHELLVILLE MD
20721-1910
US

V. Phone/Fax

Practice location:
  • Phone: 202-806-7981
  • Fax: 202-806-9311
Mailing address:
  • Phone: 240-621-0215
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY1000438
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: