Provider Demographics
NPI:1689191157
Name:GRAY, PATRICIA
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
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 1:203 N THIRD ST
Mailing Address - Street 2:
Mailing Address - City:ASHKUM
Mailing Address - State:IL
Mailing Address - Zip Code:60911-6040
Mailing Address - Country:US
Mailing Address - Phone:815-698-2212
Mailing Address - Fax:
Practice Address - Street 1:203 N THIRD ST
Practice Address - Street 2:
Practice Address - City:ASHKUM
Practice Address - State:IL
Practice Address - Zip Code:60911-6040
Practice Address - Country:US
Practice Address - Phone:815-698-2212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1636596103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool