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General NPI Number Information
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NPI Number | 1912718768
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Entity Type | Individual
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Provider Name | RANDALL GRAY PMHNP-BC
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Gender | Male
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Dates
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Enumeration Date | 01/20/2025
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Last Update Date | 10/07/2025
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Provider Practice Location Address
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Address Line | 1229 LINCOLN ST
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City | ANDERSON
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State | IN
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Zip | 46016-1693
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Country | US
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Telephone | 765-313-9850
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Fax | 765-649-9185
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Provider Business Mailing Address
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Address Line | 729 W 4TH ST APT 1
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City | ANDERSON
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State | IN
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Zip | 46016-1197
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Country | US
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Telephone | 765-639-5788
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 28158270C
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License Number State | IN
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