Provider Demographics
NPI:1891194585
Name:GRAY, STACEY (CPC)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:CPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2542 SUNGOLD DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89134-8890
Mailing Address - Country:US
Mailing Address - Phone:702-569-1917
Mailing Address - Fax:
Practice Address - Street 1:6628 SKY POINTE DR STE 115
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89131-4071
Practice Address - Country:US
Practice Address - Phone:702-620-9354
Practice Address - Fax:702-935-8945
Is Sole Proprietor?:No
Enumeration Date:2014-08-19
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVCP1185101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVCI0118OtherSTATE LICENSE