=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396237921
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIZ GRAY COUNSELING AND CONSULTING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2018
-----------------------------------------------------
Last Update Date | 04/10/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 76 PROGRESS DR STE 230D
-----------------------------------------------------
City | STAMFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06902-3600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-518-4550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 76 PROGRESS DR STE 230D
-----------------------------------------------------
City | STAMFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06902-3600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ELIZABETH GRAY
-----------------------------------------------------
Credential | LCSW, RPT
-----------------------------------------------------
Telephone | 847-899-8320
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 010205
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------