Provider Demographics
NPI:1114934742
Name:GRAY, ANNIE CONNOR
Entity Type:Individual
Prefix:
First Name:ANNIE
Middle Name:CONNOR
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 1:2085 FRONTIS PLAZA BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-5614
Mailing Address - Country:US
Mailing Address - Phone:336-277-1065
Mailing Address - Fax:336-277-9274
Practice Address - Street 1:1710 E 4TH ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3208
Practice Address - Country:US
Practice Address - Phone:704-384-7460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0010001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
2870560DMedicare ID - Type Unspecified