=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093725210
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARJORY ROBERTS GRAY PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2006
-----------------------------------------------------
Last Update Date | 02/09/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27 COLLEGE ST
-----------------------------------------------------
City | SOUTH HADLEY
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01075-6461
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 413-536-2662
-----------------------------------------------------
Fax | 413-536-2662
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16 STANTON RD
-----------------------------------------------------
City | PORTSMOUTH
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02871-3519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 413-626-4966
-----------------------------------------------------
Fax | 413-293-0693
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PS01590
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------