Provider Demographics
NPI:1588420830
Name:GRAY, ANGELA MARIE
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARIE
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 1:2057 PULASKI HWY
Mailing Address - Street 2:
Mailing Address - City:NORTH EAST
Mailing Address - State:MD
Mailing Address - Zip Code:21901-3744
Mailing Address - Country:US
Mailing Address - Phone:443-877-4044
Mailing Address - Fax:
Practice Address - Street 1:2057 PULASKI HWY
Practice Address - Street 2:
Practice Address - City:NORTH EAST
Practice Address - State:MD
Practice Address - Zip Code:21901-3744
Practice Address - Country:US
Practice Address - Phone:443-877-4044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGM1008106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist