=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013489277
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STEFANIE A. GRAY, PH.D.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2018
-----------------------------------------------------
Last Update Date | 03/23/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 132 PRINCESS PASS
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78212-5337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-570-2454
-----------------------------------------------------
Fax | 210-966-8959
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 132 PRINCESS PASS
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78212-5337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-570-2454
-----------------------------------------------------
Fax | 210-966-8959
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MEMBER
-----------------------------------------------------
Name | DR. STEFANIE A. GRAY
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 210-570-2454
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------