Healthcare Provider Details

I. General information

NPI: 1467407908
Provider Name (Legal Business Name): SAMUEL BEMISS GRAY PSY.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 04/04/2022
Certification Date: 04/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S MARSHALL ST STE 1
WINSTON SALEM NC
27101-2843
US

IV. Provider business mailing address

100 S MARSHALL ST STE 1
WINSTON SALEM NC
27101-2843
US

V. Phone/Fax

Practice location:
  • Phone: 336-276-1278
  • Fax: 336-276-1516
Mailing address:
  • Phone: 336-276-1278
  • Fax: 336-276-1516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3079
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: