=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891580825
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA KAY GRAY LMSW
-----------------------------------------------------
Gender |
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2025
-----------------------------------------------------
Last Update Date | 04/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13963 PURPLE SAGE RD
-----------------------------------------------------
City | CALDWELL
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83607-7669
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-600-7286
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1364 S EDGEWATER CIR STE 101
-----------------------------------------------------
City | NAMPA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83686-2982
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-600-7286
-----------------------------------------------------
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 | 9571751
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------