Provider Demographics
NPI:1609546100
Name:MCCRAY, AHMEN
Entity Type:Individual
Prefix:
First Name:AHMEN
Middle Name:
Last Name:MCCRAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6511 W BRANHAM LN
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-2723
Mailing Address - Country:US
Mailing Address - Phone:602-561-4816
Mailing Address - Fax:
Practice Address - Street 1:2719 W GRENADINE RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85041-3426
Practice Address - Country:US
Practice Address - Phone:602-561-4816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-16
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities