Healthcare Provider Details

I. General information

NPI: 1245620400
Provider Name (Legal Business Name): TERESA GRAY LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2015
Last Update Date: 01/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NORTH LINCOLN
DEXTER NM
88230
US

IV. Provider business mailing address

PO BOX 159
DEXTER NM
88230-0159
US

V. Phone/Fax

Practice location:
  • Phone: 575-734-5420
  • Fax: 575-734-6813
Mailing address:
  • Phone: 575-734-5420
  • Fax: 575-734-6813

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberX-08760
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: