Provider Demographics
NPI:1548615859
Name:GRAY, KATELYN (EDS)
Entity Type:Individual
Prefix:MRS
First Name:KATELYN
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:EDS
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 B
Mailing Address - Street 2:
Mailing Address - City:HAGERMAN
Mailing Address - State:NM
Mailing Address - Zip Code:88232-7501
Mailing Address - Country:US
Mailing Address - Phone:575-752-3254
Mailing Address - Fax:
Practice Address - Street 1:406 CAMBRIDGE AVE
Practice Address - Street 2:
Practice Address - City:HAGERMAN
Practice Address - State:NM
Practice Address - Zip Code:88232-9610
Practice Address - Country:US
Practice Address - Phone:575-752-3254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-25
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM343677103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool