Provider Demographics
NPI:1215041702
Name:SHELLY CLEMENS-GRAY, LMSW, LLC
Entity Type:Organization
Organization Name:SHELLY CLEMENS-GRAY, LMSW, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEMENS-GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:231-935-0574
Mailing Address - Street 1:1213 W FRONT ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2317
Mailing Address - Country:US
Mailing Address - Phone:231-935-0386
Mailing Address - Fax:231-935-0387
Practice Address - Street 1:1213 W FRONT ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2317
Practice Address - Country:US
Practice Address - Phone:231-935-0386
Practice Address - Fax:231-935-0387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010702751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty