Provider Demographics
NPI:1316225014
Name:GRAY, ANGELICA NICOLE (BCBA)
Entity Type:Individual
Prefix:MS
First Name:ANGELICA
Middle Name:NICOLE
Last Name:GRAY
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8650 COMMERCE PARK PL STE A1
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-3174
Mailing Address - Country:US
Mailing Address - Phone:317-388-8131
Mailing Address - Fax:
Practice Address - Street 1:8650 COMMERCE PARK PL STE A1
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46268-3174
Practice Address - Country:US
Practice Address - Phone:317-388-8131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-28
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1-11-8855103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201377280AMedicaid