Provider Demographics
NPI:1699013813
Name:GRAY, ELIZABETH (QBHP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:QBHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4171 N CROSSOVER RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4591
Mailing Address - Country:US
Mailing Address - Phone:479-521-1427
Mailing Address - Fax:479-521-6520
Practice Address - Street 1:1004 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BERRYVILLE
Practice Address - State:AR
Practice Address - Zip Code:72616-4330
Practice Address - Country:US
Practice Address - Phone:870-423-1077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-23
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR195097795Medicaid