Healthcare Provider Details

I. General information

NPI: 1336876994
Provider Name (Legal Business Name): GLORI GRAY, PSYD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2022
Last Update Date: 08/03/2022
Certification Date: 08/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 N. CASWELL ROAD
CHARLOTTE NC
28204
US

IV. Provider business mailing address

2117 VAIL AVENUE
CHARLOTTE NC
28207
US

V. Phone/Fax

Practice location:
  • Phone: 704-765-2549
  • Fax: 704-765-4749
Mailing address:
  • Phone: 503-547-5769
  • Fax: 704-765-4749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. GLORI GRAY
Title or Position: OWNER
Credential: PSY.D.
Phone: 503-547-5769