Provider Demographics
NPI:1225523954
Name:GRAY, TAYLOR L
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:L
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 1:1840 W HOUGHTON LAKE DR UNIT 2
Mailing Address - Street 2:
Mailing Address - City:PRUDENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48651-9672
Mailing Address - Country:US
Mailing Address - Phone:989-202-4900
Mailing Address - Fax:
Practice Address - Street 1:1840 W HOUGHTON LAKE DR UNIT 2
Practice Address - Street 2:
Practice Address - City:PRUDENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48651-9672
Practice Address - Country:US
Practice Address - Phone:989-202-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-25
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician