Provider Demographics
NPI:1528002078
Name:GRAY, STANFORD J (LCSW)
Entity Type:Individual
Prefix:MR
First Name:STANFORD
Middle Name:J
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 1:2909 KING ST STE A
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-5326
Mailing Address - Country:US
Mailing Address - Phone:870-351-5020
Mailing Address - Fax:870-382-3025
Practice Address - Street 1:2909 KING ST STE A
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-5326
Practice Address - Country:US
Practice Address - Phone:870-351-5020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2019-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1979-C1041C0700X, 1041C0700X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR171752795Medicaid
AR5Y583OtherBLUE CROSS NUMBER
AR5Y583OtherBCBS
AR5Y583OtherBLUE CROSS NUMBER
AR171752795Medicaid