Provider Demographics
NPI:1376059642
Name:GRAY, SAMANTHA DENISE
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:DENISE
Last Name:GRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3850 W ANTHONY RD
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34475-8738
Mailing Address - Country:US
Mailing Address - Phone:321-241-1170
Mailing Address - Fax:321-241-1171
Practice Address - Street 1:3856 W ANTHONY RD
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34475
Practice Address - Country:US
Practice Address - Phone:347-734-7791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-21
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician