Provider Demographics
NPI:1285631317
Name:GRAY, DOUGLAS THEODORE (LICSW)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:THEODORE
Last Name:GRAY
Suffix:
Gender:M
Credentials:LICSW
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 10822
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98909-1822
Mailing Address - Country:US
Mailing Address - Phone:509-966-2692
Mailing Address - Fax:509-965-1179
Practice Address - Street 1:211 PARSONS AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98908-1734
Practice Address - Country:US
Practice Address - Phone:509-965-1179
Practice Address - Fax:509-965-1179
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-05
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000052221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG000119613Medicare ID - Type Unspecified