Basic Information
| Provider Information | |||||||||
| NPI: | 1134499809 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAY | ||||||||
| FirstName: | KATRINA | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | LCSW, LCAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 515 CLANTON RD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282171309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043329001 | ||||||||
| FaxNumber: | 7042954937 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 DEN-MAC DR | ||||||||
| Address2: | |||||||||
| City: | BOONE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286076543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282638171 | ||||||||
| FaxNumber: | 8282630995 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2012 | ||||||||
| LastUpdateDate: | 06/26/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 101YA0400X | LCAS-21371 | NC | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | C011475 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.