Provider Demographics
NPI:1952932063
Name:GRAY, SHIRLEY CHESS
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:CHESS
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 1:301 TRAVIS DR
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:LA
Mailing Address - Zip Code:70094-2549
Mailing Address - Country:US
Mailing Address - Phone:504-442-1750
Mailing Address - Fax:
Practice Address - Street 1:1799 STUMPF BLVD STE 2
Practice Address - Street 2:
Practice Address - City:TERRYTOWN
Practice Address - State:LA
Practice Address - Zip Code:70056-3950
Practice Address - Country:US
Practice Address - Phone:504-367-4234
Practice Address - Fax:504-367-4237
Is Sole Proprietor?:No
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1321101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)