Provider Demographics
NPI:1578950630
Name:GRAY, CARRIE (BCBA)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:
Other - Last Name:JENSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11350 RANDOM HILLS RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-6044
Mailing Address - Country:US
Mailing Address - Phone:703-537-0700
Mailing Address - Fax:
Practice Address - Street 1:11350 RANDOM HILLS RD
Practice Address - Street 2:SUITE 204
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-6044
Practice Address - Country:US
Practice Address - Phone:703-537-0700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-16
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133000592103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst