Healthcare Provider Details

I. General information

NPI: 1205191434
Provider Name (Legal Business Name): GRAY J CISCO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2012
Last Update Date: 07/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 E SIDNEY AVE APT 10A
MOUNT VERNON NY
10550-1417
US

IV. Provider business mailing address

40 E SIDNEY AVE APT 10A
MOUNT VERNON NY
10550-1417
US

V. Phone/Fax

Practice location:
  • Phone: 718-313-8848
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: