Healthcare Provider Details

I. General information

NPI: 1710064217
Provider Name (Legal Business Name): MARY GRAY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 BRONX BLVD
BRONX NY
10470-1407
US

IV. Provider business mailing address

16 SHADOW LN
MONTVALE NJ
07645-1345
US

V. Phone/Fax

Practice location:
  • Phone: 718-304-7080
  • Fax: 718-920-9217
Mailing address:
  • Phone: 201-476-0939
  • Fax: 201-476-0911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberF400414
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: