MEDICARE: THALIA GRAY LAC, DIPLOOM, PHD

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	171100000X	Acupuncturist	OM000281	PA

General Provider Information

NPI Number	:	1700401353
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THALIA GRAY LAC, DIPLOOM, PHD

Provider Business Mailing Address
First Line	:	626 SUMMERLEA ST
Second Line	:
City	:	PITTSBURGH
State	:	PA
Zip	:	15232-1910
Country	:	US
Telephone Number	:	412-398-2887
Fax Number	:

Provider Business Practice Location Address
First Line	:	801 N NEGLEY AVE
Second Line	:
City	:	PITTSBURGH
State	:	PA
Zip	:	15206-1560
Country	:	US
Telephone Number	:	412-206-9865
Fax Number	:

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

Provider Enumeration Date	:	06/10/2020
Last Update Date	:	06/10/2020

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