Provider Demographics
NPI:1043428790
Name:GRAY, ELIZABETH LYNN (MA, MPH)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:LYNN
Last Name:GRAY
Suffix:
Gender:F
Credentials:MA, MPH
Other - Prefix:
Other - First Name:AMBER ELIZABETH
Other - Middle Name:LYNN
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD MPH
Mailing Address - Street 1:118 TEMBLON ST
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-1604
Mailing Address - Country:US
Mailing Address - Phone:505-983-8026
Mailing Address - Fax:505-983-8026
Practice Address - Street 1:11 CALLE MEDICO
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4705
Practice Address - Country:US
Practice Address - Phone:505-983-8026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0091071101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health