Provider Demographics
NPI:1902370729
Name:GRAY, ANNEMARIE CATHERINE (BCBA)
Entity Type:Individual
Prefix:
First Name:ANNEMARIE
Middle Name:CATHERINE
Last Name:GRAY
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:ANNEMARIE
Other - Middle Name:
Other - Last Name:ROOT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:1824 TOUBY PIKE STE B
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46901-2573
Mailing Address - Country:US
Mailing Address - Phone:765-628-7400
Mailing Address - Fax:765-450-6453
Practice Address - Street 1:3730 EDISON LAKES PKWY
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3424
Practice Address - Country:US
Practice Address - Phone:574-387-4313
Practice Address - Fax:574-204-2868
Is Sole Proprietor?:No
Enumeration Date:2019-01-15
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1-18-29893103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst