Provider Demographics
NPI:1144574757
Name:GRAY, BONNIE
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:
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 1:4034 N 18TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-6802
Mailing Address - Country:US
Mailing Address - Phone:414-449-5814
Mailing Address - Fax:414-445-6977
Practice Address - Street 1:4034 N 18TH ST
Practice Address - Street 2:3535 N 50TH STREET
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-6802
Practice Address - Country:US
Practice Address - Phone:414-449-5814
Practice Address - Fax:414-445-6977
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-04
Last Update Date:2012-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No171W00000XOther Service ProvidersContractor