Provider Demographics
NPI:1477520518
Name:GRAY, KEITH ROBERT (LCSW)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:ROBERT
Last Name:GRAY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8617 W BURLEIGH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53222-3719
Mailing Address - Country:US
Mailing Address - Phone:414-454-0161
Mailing Address - Fax:414-454-0162
Practice Address - Street 1:10437 INNOVATION DRIVE.
Practice Address - Street 2:STE 309
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226
Practice Address - Country:US
Practice Address - Phone:414-454-0161
Practice Address - Fax:414-454-0162
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7295-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical