Healthcare Provider Details

I. General information

NPI: 1619189883
Provider Name (Legal Business Name): STACY ERIN GRAY M.H.R., L.P.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 03/10/2023
Certification Date: 03/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 COLONY DR
ADA OK
74820-2297
US

IV. Provider business mailing address

1300 HOPPE BLVD. SUITE 1
ADA OK
74820
US

V. Phone/Fax

Practice location:
  • Phone: 580-272-5170
  • Fax:
Mailing address:
  • Phone: 580-436-7211
  • Fax: 580-272-5757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3592
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: