MEDICARE: STACEY GRAY CPC

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	101YP2500X	Professional Counselor	CP1185	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CI0118	OTHER	NV	STATE LICENSE

General Provider Information

NPI Number	:	1891194585
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACEY GRAY CPC

Provider Business Mailing Address
First Line	:	2542 SUNGOLD DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89134-8890
Country	:	US
Telephone Number	:	702-569-1917
Fax Number	:

Provider Business Practice Location Address
First Line	:	6628 SKY POINTE DR STE 115
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89131-4071
Country	:	US
Telephone Number	:	702-620-9354
Fax Number	:	702-935-8945

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

Provider Enumeration Date	:	08/19/2014
Last Update Date	:	05/21/2021

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Directions to “ STACEY GRAY CPC” Practice Location

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