Provider Demographics
NPI:1710926050
Name:GRAY, BONNIE LEE (PHD)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:LEE
Last Name:GRAY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 CLEVELAND AVE S
Mailing Address - Street 2:SUITE P
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-1208
Mailing Address - Country:US
Mailing Address - Phone:651-690-3808
Mailing Address - Fax:
Practice Address - Street 1:241 CLEVELAND AVE S
Practice Address - Street 2:SUITE P
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-1208
Practice Address - Country:US
Practice Address - Phone:651-690-3808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1053103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN358047400Medicaid
MN43184GROtherBLUE CROSS BLUE SHIELD
MN104210OtherUCARE
MN358047400Medicaid
R35526Medicare UPIN