Provider Demographics
NPI:1275224339
Name:GRAY, ISIAH
Entity Type:Individual
Prefix:
First Name:ISIAH
Middle Name:
Last Name:GRAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6627 ROSE ST
Mailing Address - Street 2:
Mailing Address - City:CASS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48726-1262
Mailing Address - Country:US
Mailing Address - Phone:989-872-3834
Mailing Address - Fax:989-839-4451
Practice Address - Street 1:6627 ROSE ST
Practice Address - Street 2:
Practice Address - City:CASS CITY
Practice Address - State:MI
Practice Address - Zip Code:48726-1262
Practice Address - Country:US
Practice Address - Phone:989-872-3834
Practice Address - Fax:989-839-4451
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-18
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO23-272973106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician