=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346897576
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SEAN CORNELIUS GRAY
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2019
-----------------------------------------------------
Last Update Date | 08/22/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1727 KING ST STE 105
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22314-2700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-831-7872
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1410 NORTHGATE SQ UNIT 22
-----------------------------------------------------
City | RESTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20190-5703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-407-4256
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 0904011123
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------