Healthcare Provider Details

I. General information

NPI: 1215538947
Provider Name (Legal Business Name): CARMEN D GRAY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2020
Last Update Date: 11/09/2020
Certification Date: 11/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3675 CLAGUE RD UNIT 402
NORTH OLMSTED OH
44070-1654
US

IV. Provider business mailing address

3675 CLAGUE RD UNIT 402
NORTH OLMSTED OH
44070-1654
US

V. Phone/Fax

Practice location:
  • Phone: 440-941-4431
  • Fax:
Mailing address:
  • Phone: 440-941-4431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: