=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588086995
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEIRDRE DUNHAM GRAY LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/21/2014
-----------------------------------------------------
Last Update Date | 02/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23 MAPLE ST
-----------------------------------------------------
City | MASSENA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13662-1017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-769-8441
-----------------------------------------------------
Fax | 315-769-3902
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 CHIMNEY POINT DR
-----------------------------------------------------
City | OGDENSBURG
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13669-2212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 088947
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------