Provider Demographics
NPI:1952672180
Name:VICTORIA-GRAY, ELLE (LMSW)
Entity Type:Individual
Prefix:MS
First Name:ELLE
Middle Name:
Last Name:VICTORIA-GRAY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 519
Mailing Address - Street 2:
Mailing Address - City:MC LAUGHLIN
Mailing Address - State:SD
Mailing Address - Zip Code:57642-0519
Mailing Address - Country:US
Mailing Address - Phone:605-823-4574
Mailing Address - Fax:605-823-4575
Practice Address - Street 1:301 SALE BARN ROAD
Practice Address - Street 2:
Practice Address - City:MCLAUGHLIN
Practice Address - State:SD
Practice Address - Zip Code:57642-0519
Practice Address - Country:US
Practice Address - Phone:605-823-4574
Practice Address - Fax:605-823-4575
Is Sole Proprietor?:No
Enumeration Date:2012-01-19
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0079841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical