Provider Demographics
NPI:1710064217
Name:GRAY, MARY (NP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 SHADOW LN
Mailing Address - Street 2:
Mailing Address - City:MONTVALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07645-1345
Mailing Address - Country:US
Mailing Address - Phone:201-476-0939
Mailing Address - Fax:201-476-0911
Practice Address - Street 1:4401 BRONX BLVD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10470-1407
Practice Address - Country:US
Practice Address - Phone:718-304-7080
Practice Address - Fax:718-920-9217
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF400414101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2E8101Medicare ID - Type UnspecifiedMEDICARE