Healthcare Provider Details

I. General information

NPI: 1164710497
Provider Name (Legal Business Name): LUKECIA T. GRAYSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2011
Last Update Date: 07/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 OAK TRAIL DR
MARIETTA GA
30062-7502
US

IV. Provider business mailing address

790 OAK TRAIL DR
MARIETTA GA
30062-7502
US

V. Phone/Fax

Practice location:
  • Phone: 770-977-6866
  • Fax: 770-783-8639
Mailing address:
  • Phone: 770-977-6866
  • Fax: 770-783-8639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: