Provider Demographics
NPI:1083142517
Name:GRAY, LAWANDA RAMONA
Entity Type:Individual
Prefix:
First Name:LAWANDA
Middle Name:RAMONA
Last Name:GRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:945 DANIEL MALONEY DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-8270
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:945 DANIEL MALONEY DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-8270
Practice Address - Country:US
Practice Address - Phone:757-822-9401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-29
Last Update Date:2017-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician