Healthcare Provider Details

I. General information

NPI: 1932262235
Provider Name (Legal Business Name): JULIE BETH GRAY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 08/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1337 GUSDORF ROAD SUITE E
TAOS NM
87571
US

IV. Provider business mailing address

107 TOALNE RD UNIT # 3
TAOS NM
87571-5253
US

V. Phone/Fax

Practice location:
  • Phone: 575-758-4297
  • Fax: 575-751-7237
Mailing address:
  • Phone: 575-770-1880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberM-06154
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberM-06154
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: