Basic Information
| Provider Information | |||||||||
| NPI: | 1598893315 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRAY | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | S. | ||||||||
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| Credential: | LCSWC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 618 | ||||||||
| Address2: | |||||||||
| City: | HEBRON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218300618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103763517 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9730 HEALTHWAY DRIVE | ||||||||
| Address2: | BERLIN HEALTH CENTER | ||||||||
| City: | BERLIN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106290164 | ||||||||
| FaxNumber: | 4106290185 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 11776 | MD | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.