Healthcare Provider Details

I. General information

NPI: 1609603588
Provider Name (Legal Business Name): SHAZIA GRAY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2024
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

389 MAIN ST
MALDEN MA
02148-5054
US

IV. Provider business mailing address

389 MAIN ST
MALDEN MA
02148-5054
US

V. Phone/Fax

Practice location:
  • Phone: 617-804-2773
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: