Provider Demographics
NPI:1508009887
Name:GRAY, ALICIA J (MA)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:J
Last Name:GRAY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3151 STILLMEADOW DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46214-1529
Mailing Address - Country:US
Mailing Address - Phone:317-294-5454
Mailing Address - Fax:317-295-1713
Practice Address - Street 1:3151 STILLMEADOW DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46214-1529
Practice Address - Country:US
Practice Address - Phone:317-294-5454
Practice Address - Fax:317-295-1713
Is Sole Proprietor?:No
Enumeration Date:2009-04-15
Last Update Date:2010-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200936750 AOtherWAIVER-32 CAPRT-F GRANT