Healthcare Provider Details

I. General information

NPI: 1205583234
Provider Name (Legal Business Name): SARA GRAY M.ED., CADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2022
Last Update Date: 07/19/2024
Certification Date: 07/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1044 NORTHWEST BLVD STE C
COEUR D ALENE ID
83814-2114
US

IV. Provider business mailing address

1044 NORTHWEST BLVD STE C
COEUR D ALENE ID
83814-2114
US

V. Phone/Fax

Practice location:
  • Phone: 208-930-1740
  • Fax: 208-930-1695
Mailing address:
  • Phone: 208-930-1740
  • Fax: 208-930-1695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLPC-7578
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number10223
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: