Provider Demographics
NPI:1154658565
Name:GRAY, ANDREA MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:MARIE
Last Name:GRAY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ANNIE
Other - Middle Name:
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:28 FOREST GLEN DR
Mailing Address - Street 2:
Mailing Address - City:ROCKPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04856-4603
Mailing Address - Country:US
Mailing Address - Phone:207-236-2779
Mailing Address - Fax:
Practice Address - Street 1:1152 ROCKLAND ST
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:ME
Practice Address - Zip Code:04856-6304
Practice Address - Country:US
Practice Address - Phone:207-236-2779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-05
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC124011041C0700X
MEMC107961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical