Provider Demographics
NPI:1598251795
Name:GRAY, TEZ-MIA KIMBERLY
Entity Type:Individual
Prefix:MS
First Name:TEZ-MIA
Middle Name:KIMBERLY
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 1:1100 LIME ST APT 28
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-4417
Mailing Address - Country:US
Mailing Address - Phone:904-624-5231
Mailing Address - Fax:
Practice Address - Street 1:1100 LIME ST APT 28
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-4417
Practice Address - Country:US
Practice Address - Phone:904-624-5231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities