Healthcare Provider Details

I. General information

NPI: 1235403965
Provider Name (Legal Business Name): CHRISTY GRAY RD, CD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2012
Last Update Date: 02/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 LEONARD DR
VALPARAISO IN
46383-7136
US

IV. Provider business mailing address

10948 W 100 N
MICHIGAN CITY IN
46360-9451
US

V. Phone/Fax

Practice location:
  • Phone: 219-476-1703
  • Fax:
Mailing address:
  • Phone: 219-879-2893
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number37002112A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: