Healthcare Provider Details

I. General information

NPI: 1265858831
Provider Name (Legal Business Name): MS. ANTHEA ALEXIS GRAY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2014
Last Update Date: 08/17/2023
Certification Date: 08/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 MEDICAL CENTER DR
COLUMBUS OH
43210-1229
US

IV. Provider business mailing address

700 ACKERMAN RD STE 2120
COLUMBUS OH
43202-1559
US

V. Phone/Fax

Practice location:
  • Phone: 614-293-9098
  • Fax: 614-293-3809
Mailing address:
  • Phone: 614-293-9098
  • Fax: 614-293-3809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License NumberP.07929
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: