Provider Demographics
NPI:1245620400
Name:GRAY, TERESA (LMSW)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 159
Mailing Address - Street 2:
Mailing Address - City:DEXTER
Mailing Address - State:NM
Mailing Address - Zip Code:88230-0159
Mailing Address - Country:US
Mailing Address - Phone:575-734-5420
Mailing Address - Fax:575-734-6813
Practice Address - Street 1:100 NORTH LINCOLN
Practice Address - Street 2:
Practice Address - City:DEXTER
Practice Address - State:NM
Practice Address - Zip Code:88230
Practice Address - Country:US
Practice Address - Phone:575-734-5420
Practice Address - Fax:575-734-6813
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-27
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMX-087601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical