Healthcare Provider Details

I. General information

NPI: 1932876000
Provider Name (Legal Business Name): PAMELA CARYL GRAY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2021
Last Update Date: 09/14/2021
Certification Date: 09/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 CONCORD RD STE 100
KNOXVILLE TN
37934-2941
US

IV. Provider business mailing address

4196 HIGHWAY 62 412 STE A
HARDY AR
72542-8002
US

V. Phone/Fax

Practice location:
  • Phone: 870-856-1202
  • Fax: 870-856-2107
Mailing address:
  • Phone: 870-856-1202
  • Fax: 870-856-2107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7644
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: