Provider Demographics
NPI:1023535671
Name:GRAY, KATHERINE MARIE
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:MARIE
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 1:5349 HIGHWAY 20
Mailing Address - Street 2:
Mailing Address - City:DEVILS LAKE
Mailing Address - State:ND
Mailing Address - Zip Code:58301-9646
Mailing Address - Country:US
Mailing Address - Phone:701-662-8703
Mailing Address - Fax:
Practice Address - Street 1:5349 HIGHWAY 20
Practice Address - Street 2:
Practice Address - City:DEVILS LAKE
Practice Address - State:ND
Practice Address - Zip Code:58301-9646
Practice Address - Country:US
Practice Address - Phone:701-381-2037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-24
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND$$$$$$$$$Medicaid