Healthcare Provider Details

I. General information

NPI: 1689176927
Provider Name (Legal Business Name): GRAY ALEXANDRA VARGAS PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2018
Last Update Date: 03/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 N BROADWAY
BALTIMORE MD
21205-1832
US

IV. Provider business mailing address

2931 E BIDDLE ST
BALTIMORE MD
21213-3939
US

V. Phone/Fax

Practice location:
  • Phone: 443-923-1872
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number05948
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: