Provider Demographics
NPI:1811240096
Name:GRAY, ANGELA DESIREE (PHD)
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:DESIREE
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 1:400 BRANDON AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22903-3310
Mailing Address - Country:US
Mailing Address - Phone:434-243-5150
Mailing Address - Fax:
Practice Address - Street 1:400 BRANDON AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-3310
Practice Address - Country:US
Practice Address - Phone:434-243-5150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-24
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810004455103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical