Provider Demographics
NPI:1871065524
Name:GRAY, RICHARD SR
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:
Last Name:GRAY
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2033 SEAGIRT BLVD APT 3G
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-2933
Mailing Address - Country:US
Mailing Address - Phone:516-428-7486
Mailing Address - Fax:
Practice Address - Street 1:2033 SEAGIRT BLVD APT 3G
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-2933
Practice Address - Country:US
Practice Address - Phone:516-428-7486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-19
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Multi-Specialty