Healthcare Provider Details

I. General information

NPI: 1942432240
Provider Name (Legal Business Name): PENNY J GRAY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2009
Last Update Date: 08/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 MOODY ST
SACO ME
04072-1536
US

IV. Provider business mailing address

76 SIDNEY BLVD
HAMPDEN ME
04444-1418
US

V. Phone/Fax

Practice location:
  • Phone: 800-434-3000
  • Fax:
Mailing address:
  • Phone: 207-862-4858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC5807
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: