Healthcare Provider Details

I. General information

NPI: 1275521809
Provider Name (Legal Business Name): KIRSTEN NICOLE BRAY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2005
Last Update Date: 06/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1617 W GARRISON BLVD
GASTONIA NC
28052-3635
US

IV. Provider business mailing address

PO BOX 98313
RALEIGH NC
27624-8313
US

V. Phone/Fax

Practice location:
  • Phone: 704-867-0219
  • Fax: 704-867-0216
Mailing address:
  • Phone: 919-845-0054
  • Fax: 919-845-1947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number2001-00315
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number200100315
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: