Provider Demographics
NPI:1942417696
Name:GRAY, MICHELLE DERESCHUK (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:DERESCHUK
Last Name:GRAY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:DERESCHUK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 2456
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86003-2456
Mailing Address - Country:US
Mailing Address - Phone:928-774-3400
Mailing Address - Fax:
Practice Address - Street 1:1515 N SAN FRANCISCO ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1435
Practice Address - Country:US
Practice Address - Phone:928-774-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2009-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3096103T00000X
AZLMFT0324106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZPHD3096Medicare ID - Type UnspecifiedMEDICARE IDENTIFIER