Provider Demographics
NPI:1003575242
Name:GRAY, SHAHETAH
Entity Type:Individual
Prefix:
First Name:SHAHETAH
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1311
Mailing Address - Street 2:
Mailing Address - City:BYRON
Mailing Address - State:GA
Mailing Address - Zip Code:31008-1311
Mailing Address - Country:US
Mailing Address - Phone:478-225-8060
Mailing Address - Fax:
Practice Address - Street 1:940 GA HIGHWAY 96 STE A
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-2587
Practice Address - Country:US
Practice Address - Phone:229-817-5454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-15
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator