Basic Information
| Provider Information | |||||||||
| NPI: | 1528002078 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAY | ||||||||
| FirstName: | STANFORD | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2909 KING ST STE A | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724015326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703515020 | ||||||||
| FaxNumber: | 8703823025 | ||||||||
| Practice Location | |||||||||
| Address1: | 2909 KING ST STE A | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724015326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703515020 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 03/10/2019 | ||||||||
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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 | 1979-C | AR | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 171752795 | 05 | AR | MEDICAID | 5Y583 | 01 | AR | BLUE CROSS NUMBER | OTHER | 5Y583 | 01 | AR | BCBS | OTHER |