Provider Demographics
NPI:1508084047
Name:GRAY, MICHELE DIANE (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:DIANE
Last Name:GRAY
Suffix:
Gender:F
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:PO BOX 383
Mailing Address - Street 2:
Mailing Address - City:ROCKLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04841-0383
Mailing Address - Country:US
Mailing Address - Phone:207-596-6044
Mailing Address - Fax:
Practice Address - Street 1:21 LIMEROCK ST
Practice Address - Street 2:ROOM 217 & 219
Practice Address - City:ROCKLAND
Practice Address - State:ME
Practice Address - Zip Code:04841-2977
Practice Address - Country:US
Practice Address - Phone:207-596-6044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC45351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM5510Medicare ID - Type Unspecified