Provider Demographics
NPI:1255683611
Name:GRAY, TINA MICHELLE
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MICHELLE
Last Name:GRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:MICHELLE
Other - Last Name:REED
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 953
Mailing Address - Street 2:721 SW FORTUNE STREET
Mailing Address - City:LANGSTON
Mailing Address - State:OK
Mailing Address - Zip Code:73050-0953
Mailing Address - Country:US
Mailing Address - Phone:405-513-1353
Mailing Address - Fax:
Practice Address - Street 1:721 SOUTH WEST FORTUNE ST
Practice Address - Street 2:
Practice Address - City:LANGSTON
Practice Address - State:OK
Practice Address - Zip Code:73050-0953
Practice Address - Country:US
Practice Address - Phone:405-513-1353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-10
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health