Provider Demographics
NPI:1780107524
Name:GRAY, LATRICE KIANE (MSW, LCSW-C, RPT)
Entity type:Individual
Prefix:
First Name:LATRICE
Middle Name:KIANE
Last Name:GRAY
Suffix:
Gender:F
Credentials:MSW, LCSW-C, RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5304 CEDAR DR
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21613-4404
Mailing Address - Country:US
Mailing Address - Phone:410-929-7427
Mailing Address - Fax:
Practice Address - Street 1:5304 CEDAR DR
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21613-4404
Practice Address - Country:US
Practice Address - Phone:410-929-7427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-24
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18674104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD18674OtherMARYLAND BOARD OF SOCIAL WORK