MEDICARE: KELLY B GRAY LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	2642-C	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	5AC40	OTHER	AR	BCBS

General Provider Information

NPI Number	:	1346476165
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY B GRAY LCSW

Provider Business Mailing Address
First Line	:	614 E EMMA AVE STE 300
Second Line	:
City	:	SPRINGDALE
State	:	AR
Zip	:	72764-4469
Country	:	US
Telephone Number	:	479-751-7417
Fax Number	:	479-751-4898

Provider Business Practice Location Address
First Line	:	1233 W POPLAR ST
Second Line	:
City	:	ROGERS
State	:	AR
Zip	:	72756-4245
Country	:	US
Telephone Number	:	479-636-9235
Fax Number	:	479-631-0374

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/08/2009
Last Update Date	:	10/05/2012

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