=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710064217
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY GRAY NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4401 BRONX BLVD
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10470-1407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-304-7080
-----------------------------------------------------
Fax | 718-920-9217
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16 SHADOW LN
-----------------------------------------------------
City | MONTVALE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07645-1345
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-476-0939
-----------------------------------------------------
Fax | 201-476-0911
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | F400414
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------