Healthcare Provider Details

I. General information

NPI: 1922963594
Provider Name (Legal Business Name): SHANE CHRISTOPHER GRAY CADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

659 HOGAN RD
BANGOR ME
04401-3626
US

IV. Provider business mailing address

194 GRIFFIN RD APT 606
BANGOR ME
04401-2841
US

V. Phone/Fax

Practice location:
  • Phone: 207-973-0400
  • Fax: 207-973-1881
Mailing address:
  • Phone: 207-973-0400
  • Fax: 207-973-1881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCAC9159
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: