Provider Demographics
NPI:1932262235
Name:GRAY, JULIE BETH (LCSW)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:BETH
Last Name:GRAY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 TOALNE RD
Mailing Address - Street 2:UNIT # 3
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-5253
Mailing Address - Country:US
Mailing Address - Phone:575-770-1880
Mailing Address - Fax:
Practice Address - Street 1:1337 GUSDORF ROAD
Practice Address - Street 2:SUITE E
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571
Practice Address - Country:US
Practice Address - Phone:575-758-4297
Practice Address - Fax:575-751-7237
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-061541041S0200X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM26523779Medicaid