Provider Demographics
NPI:1073718656
Name:GRAY, SHARON L (PSYCHOLOGIST)
Entity Type:Individual
Prefix:MS
First Name:SHARON
Middle Name:L
Last Name:GRAY
Suffix:
Gender:F
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:477 S NICOLET RD
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-8270
Mailing Address - Country:US
Mailing Address - Phone:920-882-6610
Mailing Address - Fax:920-882-6611
Practice Address - Street 1:477 S NICOLET RD
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-8270
Practice Address - Country:US
Practice Address - Phone:920-882-6610
Practice Address - Fax:920-882-6611
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-15
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3086-57103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40998100Medicaid