Provider Demographics
NPI:1619325388
Name:GRAY, SHANEQUA (LLMSW)
Entity Type:Individual
Prefix:
First Name:SHANEQUA
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 W DEWEY ST
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48505-4001
Mailing Address - Country:US
Mailing Address - Phone:972-802-1834
Mailing Address - Fax:
Practice Address - Street 1:17456 KINGSBROOKE CIR
Practice Address - Street 2:APT 102
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-3769
Practice Address - Country:US
Practice Address - Phone:586-846-6004
Practice Address - Fax:844-280-3924
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-02
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801098492104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker