Provider Demographics
NPI:1336297514
Name:GRAY, LORRAINE L (PHD)
Entity Type:Individual
Prefix:DR
First Name:LORRAINE
Middle Name:L
Last Name:GRAY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1675 MASSACHUSETTS AVE
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-1836
Mailing Address - Country:US
Mailing Address - Phone:617-816-4587
Mailing Address - Fax:
Practice Address - Street 1:1675 MASSACHUSETTS AVE
Practice Address - Street 2:SUITE 1B
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-1836
Practice Address - Country:US
Practice Address - Phone:617-816-4587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7945103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW06143OtherBC&BS PROVIDER ID #