Basic Information
| Provider Information | |||||||||
| NPI: | 1154846467 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAY | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 405 S CLAIRBORNE RD STE 2 | ||||||||
| Address2: | |||||||||
| City: | OLATHE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660621774 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9137303661 | ||||||||
| FaxNumber: | 9137681944 | ||||||||
| Practice Location | |||||||||
| Address1: | 407 S CLAIRBORNE RD STE 104 | ||||||||
| Address2: | |||||||||
| City: | OLATHE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660621744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9137303661 | ||||||||
| FaxNumber: | 9137681944 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2017 | ||||||||
| LastUpdateDate: | 02/17/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 9411 | KS | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 5073 | KS | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 201164920 | 05 | KS | MEDICAID |