MEDICARE: MR. KEITH B GRAY II

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1841594595
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KEITH B GRAY II

Provider Business Mailing Address
First Line	:	8901 S SANTA FE AVE
Second Line	:	# E
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73139-8413
Country	:	US
Telephone Number	:	405-605-5757
Fax Number	:	405-605-5775

Provider Business Practice Location Address
First Line	:	8901 S SANTA FE AVE
Second Line	:	# E
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73139-8413
Country	:	US
Telephone Number	:	405-605-5757
Fax Number	:	405-605-5775

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

Provider Enumeration Date	:	01/10/2011
Last Update Date	:	01/10/2011

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