Provider Demographics
NPI:1629840046
Name:GRAY, TERRI D (PMHNP)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:D
Last Name:GRAY
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 CARL DR
Mailing Address - Street 2:
Mailing Address - City:ROUND LAKE BEACH
Mailing Address - State:IL
Mailing Address - Zip Code:60073-2209
Mailing Address - Country:US
Mailing Address - Phone:773-449-8060
Mailing Address - Fax:
Practice Address - Street 1:1203 W AUGUSTA BLVD STE 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-4327
Practice Address - Country:US
Practice Address - Phone:773-248-2255
Practice Address - Fax:773-304-4143
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-30
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.028479363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty