Provider Demographics
NPI:1043791262
Name:GRAY, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:GRAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:449 E SAINT PETER ST
Mailing Address - Street 2:
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70560-3752
Mailing Address - Country:US
Mailing Address - Phone:337-321-9204
Mailing Address - Fax:
Practice Address - Street 1:449 E SAINT PETER ST
Practice Address - Street 2:
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70560-3752
Practice Address - Country:US
Practice Address - Phone:337-321-9204
Practice Address - Fax:337-321-9210
Is Sole Proprietor?:No
Enumeration Date:2018-08-25
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator