Provider Demographics
NPI:1558424515
Name:GRAY, AMY L (LISW-S)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:GRAY
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69902 MOUNT HERMON RD
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:OH
Mailing Address - Zip Code:43725-9464
Mailing Address - Country:US
Mailing Address - Phone:740-705-1543
Mailing Address - Fax:
Practice Address - Street 1:1100 FAIRY FALLS DR STE 4
Practice Address - Street 2:
Practice Address - City:COSHOCTON
Practice Address - State:OH
Practice Address - Zip Code:43812-2803
Practice Address - Country:US
Practice Address - Phone:740-722-9416
Practice Address - Fax:740-722-9418
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH954452101YA0400X
OHI 00203571041C0700X
OHI.0020357-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH30503Medicare PIN