Provider Demographics
NPI:1447950688
Name:GRAY, ANGELA DORENE (LSWA-P, CDSVRP)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:DORENE
Last Name:GRAY
Suffix:
Gender:F
Credentials:LSWA-P, CDSVRP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15845 STATE HIGHWAY 31
Mailing Address - Street 2:
Mailing Address - City:COALGATE
Mailing Address - State:OK
Mailing Address - Zip Code:74538-3865
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15845 STATE HIGHWAY 31
Practice Address - Street 2:
Practice Address - City:COALGATE
Practice Address - State:OK
Practice Address - Zip Code:74538-3865
Practice Address - Country:US
Practice Address - Phone:580-579-1328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator