Healthcare Provider Details

I. General information

NPI: 1952672180
Provider Name (Legal Business Name): ELLE VICTORIA-GRAY LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2012
Last Update Date: 03/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 SALE BARN ROAD
MCLAUGHLIN SD
57642-0519
US

IV. Provider business mailing address

PO BOX 519
MC LAUGHLIN SD
57642-0519
US

V. Phone/Fax

Practice location:
  • Phone: 605-823-4574
  • Fax: 605-823-4575
Mailing address:
  • Phone: 605-823-4574
  • Fax: 605-823-4575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number007984
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: