Healthcare Provider Details

I. General information

NPI: 1841646411
Provider Name (Legal Business Name): AMBER GRAY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2016
Last Update Date: 07/27/2021
Certification Date: 07/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 FELICIA AVE
TALLULAH LA
71282
US

IV. Provider business mailing address

1705 FELICIA AVE
TALLULAH LA
71282-8203
US

V. Phone/Fax

Practice location:
  • Phone: 318-574-1232
  • Fax: 318-574-8646
Mailing address:
  • Phone: 318-574-1232
  • Fax: 318-574-8646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6845
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: