Provider Demographics
NPI:1912033648
Name:GRAY, BERNARD GEORGE (PHD)
Entity Type:Individual
Prefix:DR
First Name:BERNARD
Middle Name:GEORGE
Last Name:GRAY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 PARK LN
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-2906
Mailing Address - Country:US
Mailing Address - Phone:800-923-0460
Mailing Address - Fax:617-524-1045
Practice Address - Street 1:14 PARK LN
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-2906
Practice Address - Country:US
Practice Address - Phone:800-923-0460
Practice Address - Fax:617-524-1045
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1315103TA0400X, 103TA0700X, 103TC0700X, 103TF0000X, 103T00000X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAWO1138OtherBLUE CROSS BLUE SHIELD
MAWO1138Medicare ID - Type Unspecified