Provider Demographics
NPI:1194598953
Name:GRAY, VENIDA
Entity type:Individual
Prefix:
First Name:VENIDA
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 1:10 CARNEY CT APT 107
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-2751
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:235 WELLESLEY ST
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:MA
Practice Address - Zip Code:02493-1572
Practice Address - Country:US
Practice Address - Phone:781-768-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-03
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN275038163W00000X, 364SP0813X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0813XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Geropsychiatric
No163W00000XNursing Service ProvidersRegistered Nurse