Provider Demographics
NPI:1801610605
Name:GRAY, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
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 1:3135 3RD ST NE
Mailing Address - Street 2:
Mailing Address - City:CENTER POINT
Mailing Address - State:AL
Mailing Address - Zip Code:35215-2033
Mailing Address - Country:US
Mailing Address - Phone:205-515-9350
Mailing Address - Fax:
Practice Address - Street 1:1189 ALLBRITTON RD
Practice Address - Street 2:
Practice Address - City:WARRIOR
Practice Address - State:AL
Practice Address - Zip Code:35180-2663
Practice Address - Country:US
Practice Address - Phone:205-244-3085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-09
Last Update Date:2024-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-128598163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)