Provider Demographics
NPI:1679051007
Name:GRAY, JOANNE SULLIVAN (LCSW)
Entity type:Individual
Prefix:
First Name:JOANNE
Middle Name:SULLIVAN
Last Name:GRAY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:BELMAR
Mailing Address - State:NJ
Mailing Address - Zip Code:07719-2111
Mailing Address - Country:US
Mailing Address - Phone:732-681-8717
Mailing Address - Fax:
Practice Address - Street 1:200 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:MANASQUAN
Practice Address - State:NJ
Practice Address - Zip Code:08736-1352
Practice Address - Country:US
Practice Address - Phone:609-916-6445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-28
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06397500104100000X
NJ44SC059424001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0029807Medicaid