Provider Demographics
NPI:1477079416
Name:GRAY, MARLENE A
Entity Type:Individual
Prefix:
First Name:MARLENE
Middle Name:A
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:PO BOX 180
Mailing Address - Street 2:
Mailing Address - City:SELAWIK
Mailing Address - State:AK
Mailing Address - Zip Code:99770-0180
Mailing Address - Country:US
Mailing Address - Phone:907-484-2199
Mailing Address - Fax:907-484-2119
Practice Address - Street 1:180 TUNDRA ROAD
Practice Address - Street 2:
Practice Address - City:SELAWIK
Practice Address - State:AK
Practice Address - Zip Code:99770-0180
Practice Address - Country:US
Practice Address - Phone:907-484-2199
Practice Address - Fax:907-484-2119
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK0600402000Medicaid