Provider Demographics
NPI:1336859594
Name:GRAY, ELLEN FAY (QBHS)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:FAY
Last Name:GRAY
Suffix:
Gender:F
Credentials:QBHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6500 LUCAS LN
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45133-8132
Mailing Address - Country:US
Mailing Address - Phone:937-763-8222
Mailing Address - Fax:
Practice Address - Street 1:149 CHILLICOTHE AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OH
Practice Address - Zip Code:45133-1533
Practice Address - Country:US
Practice Address - Phone:937-393-9662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-29
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty