Provider Demographics
NPI:1558012401
Name:GRAY, KILA
Entity Type:Individual
Prefix:
First Name:KILA
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 1:11362 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62439-4325
Mailing Address - Country:US
Mailing Address - Phone:618-943-3302
Mailing Address - Fax:
Practice Address - Street 1:11362 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62439-4325
Practice Address - Country:US
Practice Address - Phone:618-943-3302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-12
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health