Provider Demographics
NPI:1053760108
Name:GRAY HEALTH INC
Entity type:Organization
Organization Name:GRAY HEALTH INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:TROVER
Authorized Official - Middle Name:GRAY
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MSW/LCSW/CADC/CODP
Authorized Official - Phone:773-373-9175
Mailing Address - Street 1:6033 N SHERIDAN RD APT 19AB
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-3003
Mailing Address - Country:US
Mailing Address - Phone:773-373-9175
Mailing Address - Fax:320-205-1753
Practice Address - Street 1:5214 N WESTERN AVE STE 303
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-2592
Practice Address - Country:US
Practice Address - Phone:773-373-9175
Practice Address - Fax:320-205-1753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-09
Last Update Date:2021-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490159151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty