Provider Demographics
NPI:1497444194
Name:GRAY, ATHELIA
Entity Type:Individual
Prefix:
First Name:ATHELIA
Middle Name:
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 1:2900 GREYSTONE LN APT 8
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-8454
Mailing Address - Country:US
Mailing Address - Phone:231-357-7772
Mailing Address - Fax:
Practice Address - Street 1:625 KENMOOR AVE SE STE 301
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2395
Practice Address - Country:US
Practice Address - Phone:267-300-4857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-08
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician