Provider Demographics
NPI:1346476165
Name:GRAY, KELLY B (LCSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:B
Last Name:GRAY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:B
Other - Last Name:REED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:614 E EMMA AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-4469
Mailing Address - Country:US
Mailing Address - Phone:479-751-7417
Mailing Address - Fax:479-751-4898
Practice Address - Street 1:1233 W POPLAR ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-4245
Practice Address - Country:US
Practice Address - Phone:479-636-9235
Practice Address - Fax:479-631-0374
Is Sole Proprietor?:No
Enumeration Date:2009-06-08
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2642-C104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR177258795Medicaid
AR5AC40OtherBCBS