Provider Demographics
NPI:1023416278
Name:GRAY, RITA II (PSYD)
Entity type:Individual
Prefix:
First Name:RITA
Middle Name:
Last Name:GRAY
Suffix:II
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 ELLA AVE
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60433-2799
Mailing Address - Country:US
Mailing Address - Phone:815-727-5904
Mailing Address - Fax:815-727-0136
Practice Address - Street 1:501 ELLA AVE
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60433-2799
Practice Address - Country:US
Practice Address - Phone:815-727-5904
Practice Address - Fax:815-727-0136
Is Sole Proprietor?:No
Enumeration Date:2014-12-19
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071006902103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical