Provider Demographics
NPI:1376067926
Name:GRAY, ILA ANN (LCDC III)
Entity Type:Individual
Prefix:
First Name:ILA
Middle Name:ANN
Last Name:GRAY
Suffix:
Gender:F
Credentials:LCDC III
Other - Prefix:
Other - First Name:ILA
Other - Middle Name:ANN
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:201 WEST SPRINGDALE AVE.
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37917
Mailing Address - Country:US
Mailing Address - Phone:865-637-9711
Mailing Address - Fax:
Practice Address - Street 1:201 WEST SPRINGDALE AVE.
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37917
Practice Address - Country:US
Practice Address - Phone:865-637-9711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-26
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
OHLCDC.161081-3101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor