Provider Demographics
NPI:1114000288
Name:GRAY, CORNEL S (LCSW)
Entity Type:Individual
Prefix:
First Name:CORNEL
Middle Name:S
Last Name:GRAY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1314 E WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47501-2860
Mailing Address - Country:US
Mailing Address - Phone:812-254-2760
Mailing Address - Fax:812-257-8602
Practice Address - Street 1:1402 GRAND AVE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IN
Practice Address - Zip Code:47501-2122
Practice Address - Country:US
Practice Address - Phone:812-254-8634
Practice Address - Fax:812-257-8609
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34003788A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200190CMedicare ID - Type Unspecified