Provider Demographics
NPI:1821354010
Name:GRAY, JAMES ALBERT (LADC)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:ALBERT
Last Name:GRAY
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PERHAM
Mailing Address - State:MN
Mailing Address - Zip Code:56573-1934
Mailing Address - Country:US
Mailing Address - Phone:218-346-6100
Mailing Address - Fax:218-346-6112
Practice Address - Street 1:840 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PERHAM
Practice Address - State:MN
Practice Address - Zip Code:56573-1934
Practice Address - Country:US
Practice Address - Phone:218-346-6100
Practice Address - Fax:218-346-6112
Is Sole Proprietor?:No
Enumeration Date:2012-04-02
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN300475101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN43-2066657OtherFEIN
MN10348381CDTMedicare UPIN