Provider Demographics
NPI:1043420227
Name:GRAY, ITHA JOYCE (ICADC)
Entity Type:Individual
Prefix:
First Name:ITHA
Middle Name:JOYCE
Last Name:GRAY
Suffix:
Gender:F
Credentials:ICADC
Other - Prefix:
Other - First Name:JOYCE
Other - Middle Name:
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ICADC
Mailing Address - Street 1:204 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:HOLDENVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74848-9537
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:118 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HOLDENVILLE
Practice Address - State:OK
Practice Address - Zip Code:74848-3208
Practice Address - Country:US
Practice Address - Phone:405-379-5256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK252101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)