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General NPI Number Information
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NPI Number | 1942417696
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Entity Type | Individual
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Provider Name | MICHELLE DERESCHUK GRAY PH.D.
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Gender | Female
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Dates
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Enumeration Date | 05/16/2007
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Last Update Date | 02/13/2009
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Provider Practice Location Address
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Address Line | 1515 N SAN FRANCISCO ST
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City | FLAGSTAFF
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State | AZ
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Zip | 86001-1435
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Country | US
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Telephone | 928-774-3400
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2456
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City | FLAGSTAFF
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State | AZ
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Zip | 86003-2456
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Country | US
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Telephone | 928-774-3400
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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 | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 3096
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | LMFT0324
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License Number State | AZ
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