MEDICARE: JUDITH ANNE GRAY APRN

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	R039465	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	136851000	OTHER	MD	MAGELLAN
2	PB64960	OTHER	MD	APS
3	425142	OTHER	MD	MAMSI
4	K2890001	OTHER	DC	CAREFIRST BLUE CROSS BLUE
5	563BJA	OTHER	MD	CAREFIRST BCBS

General Provider Information

NPI Number	:	1952384158
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUDITH ANNE GRAY APRN

Provider Business Mailing Address
First Line	:	25485 HARCUM WHARF RD
Second Line	:
City	:	EDEN
State	:	MD
Zip	:	21822-2167
Country	:	US
Telephone Number	:	443-880-2995
Fax Number	:	817-877-7197

Provider Business Practice Location Address
First Line	:	25485 HARCUM WHARF RD
Second Line	:
City	:	EDEN
State	:	MD
Zip	:	21822-2167
Country	:	US
Telephone Number	:	443-880-2995
Fax Number	:	877-817-7197

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

Provider Enumeration Date	:	11/22/2005
Last Update Date	:	08/13/2012

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