Basic Information
| Provider Information | |||||||||
| NPI: | 1699013813 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAY | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | |||||||||
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| Credential: | QBHP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4171 N CROSSOVER RD | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727034591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4795211427 | ||||||||
| FaxNumber: | 4795216520 | ||||||||
| Practice Location | |||||||||
| Address1: | 1004 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BERRYVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726164330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8704231077 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2013 | ||||||||
| LastUpdateDate: | 07/13/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 195097795 | 05 | AR | MEDICAID |