Healthcare Provider Details

I. General information

NPI: 1114934742
Provider Name (Legal Business Name): ANNIE CONNOR GRAY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 01/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 E 4TH ST
CHARLOTTE NC
28204-3208
US

IV. Provider business mailing address

2085 FRONTIS PLAZA BLVD
WINSTON SALEM NC
27103-5614
US

V. Phone/Fax

Practice location:
  • Phone: 704-384-7460
  • Fax:
Mailing address:
  • Phone: 336-277-1065
  • Fax: 336-277-9274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC001000
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: