Provider Demographics
NPI:1205583234
Name:GRAY, SARA (MED, CADC)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:MED, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1044 NORTHWEST BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2114
Mailing Address - Country:US
Mailing Address - Phone:208-930-1740
Mailing Address - Fax:208-930-1695
Practice Address - Street 1:1044 NORTHWEST BLVD STE C
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2114
Practice Address - Country:US
Practice Address - Phone:208-930-1740
Practice Address - Fax:208-930-1695
Is Sole Proprietor?:No
Enumeration Date:2022-03-09
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID10223101YA0400X
IDLPC-7578101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1437270097Medicaid