Provider Demographics
NPI:1134296601
Name:MCCRAY, CHARLES
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:MCCRAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MARGUERITE
Other - Middle Name:
Other - Last Name:MCCRAY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8225 W TUCKEY LN
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85303-3210
Mailing Address - Country:US
Mailing Address - Phone:623-463-1936
Mailing Address - Fax:
Practice Address - Street 1:8225 W TUCKEY LN
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85303-3210
Practice Address - Country:US
Practice Address - Phone:623-463-1936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9094385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ905903OtherAHCCCS ID