Provider Demographics
NPI:1407525249
Name:GRAY, DEBRA J
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:J
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 1:290 CARRIAGE OAKS DR
Mailing Address - Street 2:
Mailing Address - City:TYRONE
Mailing Address - State:GA
Mailing Address - Zip Code:30290-1521
Mailing Address - Country:US
Mailing Address - Phone:404-226-9550
Mailing Address - Fax:
Practice Address - Street 1:290 CARRIAGE OAKS DR
Practice Address - Street 2:
Practice Address - City:TYRONE
Practice Address - State:GA
Practice Address - Zip Code:30290-1521
Practice Address - Country:US
Practice Address - Phone:404-226-9550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-07
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA85-3806492347C00000X, 251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
No347C00000XTransportation ServicesPrivate Vehicle