Provider Demographics
NPI:1821304189
Name:GRAY, REBECCA FOWLIE (LCSW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:FOWLIE
Last Name:GRAY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:WOODS
Other - Last Name:FOWLIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:22 WARD BROOK RD
Mailing Address - Street 2:
Mailing Address - City:WISCASSET
Mailing Address - State:ME
Mailing Address - Zip Code:04578-4642
Mailing Address - Country:US
Mailing Address - Phone:207-215-0789
Mailing Address - Fax:
Practice Address - Street 1:306 RODMAN RD
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210-3830
Practice Address - Country:US
Practice Address - Phone:207-215-0789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-25
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC126681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME435945699OtherPROVIDER ENROLLMENT