Provider Demographics
NPI:1669135638
Name:GRAY, LILLIAN
Entity type:Individual
Prefix:
First Name:LILLIAN
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4346 STARKEY RD STE 1
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-0605
Mailing Address - Country:US
Mailing Address - Phone:540-772-8043
Mailing Address - Fax:
Practice Address - Street 1:44 CATAWBA RD STE 103
Practice Address - Street 2:
Practice Address - City:DALEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24083-2694
Practice Address - Country:US
Practice Address - Phone:540-772-8043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-18
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
16945225A00000X
VA0704015708101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist