Provider Demographics
NPI:1164056297
Name:GRAY, LYDIA NICOLE
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:NICOLE
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 1:5187 ROUTE 60 EAST
Mailing Address - Street 2:SUITE 11
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25705
Mailing Address - Country:US
Mailing Address - Phone:304-302-0526
Mailing Address - Fax:304-302-0527
Practice Address - Street 1:5187 ROUTE 60 EAST
Practice Address - Street 2:SUITE 11
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25705
Practice Address - Country:US
Practice Address - Phone:304-302-0526
Practice Address - Fax:304-302-0527
Is Sole Proprietor?:No
Enumeration Date:2020-02-27
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVBP00945555104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker