Provider Demographics
NPI:1093830366
Name:GRAY, TAMARA RAQUEL (BSED)
Entity type:Individual
Prefix:MRS
First Name:TAMARA
Middle Name:RAQUEL
Last Name:GRAY
Suffix:
Gender:F
Credentials:BSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 AFTON ST
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19111-3428
Mailing Address - Country:US
Mailing Address - Phone:215-342-4479
Mailing Address - Fax:
Practice Address - Street 1:112 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19102-1510
Practice Address - Country:US
Practice Address - Phone:215-568-0860
Practice Address - Fax:215-568-0769
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor