Provider Demographics
NPI:1346897576
Name:GRAY, SEAN CORNELIUS
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:CORNELIUS
Last Name:GRAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 NORTHGATE SQ UNIT 22
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-5703
Mailing Address - Country:US
Mailing Address - Phone:703-407-4256
Mailing Address - Fax:
Practice Address - Street 1:1727 KING ST STE 105
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-2700
Practice Address - Country:US
Practice Address - Phone:703-831-7872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-22
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040111231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty