Provider Demographics
NPI:1033190152
Name:GRAY, CHRISTINE W (PHD)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:W
Last Name:GRAY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:
Other - Last Name:WITTSTOCK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 20092
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82003-7002
Mailing Address - Country:US
Mailing Address - Phone:307-630-4729
Mailing Address - Fax:
Practice Address - Street 1:415 W 27TH ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001
Practice Address - Country:US
Practice Address - Phone:307-630-4729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY427103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY103TC0700XOtherDOMHA MCD TAXONOMY
WY21092OtherDOMHA MCR
WY103TC0700XOtherDOMHA MCD TAXONOMY