Provider Demographics
NPI:1376984054
Name:WRAY, GROVER LOUIS (LMSW)
Entity type:Individual
Prefix:MR
First Name:GROVER
Middle Name:LOUIS
Last Name:WRAY
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3440 E 200 N
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-5400
Mailing Address - Country:US
Mailing Address - Phone:208-754-4913
Mailing Address - Fax:
Practice Address - Street 1:2222 TETON PLZ STE 2
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6485
Practice Address - Country:US
Practice Address - Phone:208-522-4026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-10
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID690104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID690Medicaid