Healthcare Provider Details

I. General information

NPI: 1447079439
Provider Name (Legal Business Name): ANTOINE GRAY LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2024
Last Update Date: 01/06/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N HOWARD ST STE W
SPOKANE WA
99201-0508
US

IV. Provider business mailing address

100 N HOWARD ST STE W
SPOKANE WA
99201-0508
US

V. Phone/Fax

Practice location:
  • Phone: 509-635-3880
  • Fax:
Mailing address:
  • Phone: 509-635-3880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMC61620781
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number105343
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: