Provider Demographics
NPI:1215560222
Name:GRAY, JILLIAN (BCBA)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 ORIENTA AVE STE 1011
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-5675
Mailing Address - Country:US
Mailing Address - Phone:877-823-4283
Mailing Address - Fax:
Practice Address - Street 1:4817 EHRLICH RD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33624-2037
Practice Address - Country:US
Practice Address - Phone:877-823-4283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-18
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106E00000X
1-21-53890103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst