Provider Demographics
NPI:1295012359
Name:GRAY, ELIZABETH A (MSOTR)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:A
Last Name:GRAY
Suffix:
Gender:F
Credentials:MSOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1270 STATE ROUTE 213
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-8847
Mailing Address - Country:US
Mailing Address - Phone:845-849-5466
Mailing Address - Fax:
Practice Address - Street 1:4885 ROUTE 9
Practice Address - Street 2:
Practice Address - City:STAATSBURG
Practice Address - State:NY
Practice Address - Zip Code:12580-6028
Practice Address - Country:US
Practice Address - Phone:845-889-9455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-03
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003814-1251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services