=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578956272
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TONYA MICHELLE GRAY MSW, LCSW-A, LCAS-A
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2015
-----------------------------------------------------
Last Update Date | 03/05/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1210 S MAIN ST
-----------------------------------------------------
City | LILLINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27546-7924
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-893-7233
-----------------------------------------------------
Fax | 910-893-3508
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 728
-----------------------------------------------------
City | LILLINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27546-0728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-893-7233
-----------------------------------------------------
Fax | 910-893-3508
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | LCAS-20375
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | P008625
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------