Healthcare Provider Details

I. General information

NPI: 1164659975
Provider Name (Legal Business Name): ALICE MARIE GRAY PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2009
Last Update Date: 11/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 E 17TH ST
IDAHO FALLS ID
83404-6375
US

IV. Provider business mailing address

1260 GARY ST
BLACKFOOT ID
83221-2009
US

V. Phone/Fax

Practice location:
  • Phone: 310-365-3762
  • Fax: 208-529-3184
Mailing address:
  • Phone: 310-365-3762
  • Fax: 208-529-3184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCPC -4606
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: