Provider Demographics
NPI:1740201367
Name:GRAY, ANGELA EILEEN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:EILEEN
Last Name:GRAY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 NORTH LOOP W STE 1060
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77008-1664
Mailing Address - Country:US
Mailing Address - Phone:816-248-3043
Mailing Address - Fax:713-338-2371
Practice Address - Street 1:1415 NORTH LOOP W STE 1060
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77008-1664
Practice Address - Country:US
Practice Address - Phone:816-248-3043
Practice Address - Fax:713-338-2371
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005013077104100000X
TX630491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3657405Medicaid
MO497286902Medicaid