Provider Demographics
NPI:1164659975
Name:GRAY, ALICE MARIE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ALICE
Middle Name:MARIE
Last Name:GRAY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1260 GARY ST
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-2009
Mailing Address - Country:US
Mailing Address - Phone:310-365-3762
Mailing Address - Fax:208-529-3184
Practice Address - Street 1:1740 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6375
Practice Address - Country:US
Practice Address - Phone:310-365-3762
Practice Address - Fax:208-529-3184
Is Sole Proprietor?:No
Enumeration Date:2009-06-18
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC -4606101YM0800X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)