Provider Demographics
NPI:1619462132
Name:GRAY, THERESA (LMSW)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 AKERS MILL RD SE APT E5
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-3226
Mailing Address - Country:US
Mailing Address - Phone:770-296-2929
Mailing Address - Fax:
Practice Address - Street 1:4595 TOWNE LAKE PARKWAY
Practice Address - Street 2:BUILDING 300, SUITE 250
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189
Practice Address - Country:US
Practice Address - Phone:678-592-5779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-27
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker