Provider Demographics
NPI:1023528791
Name:GRAY, AMANDA BREAUX (LMSW)
Entity type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:BREAUX
Last Name:GRAY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:457 BLUE LAKES BLVD S
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-7855
Mailing Address - Country:US
Mailing Address - Phone:208-539-4900
Mailing Address - Fax:
Practice Address - Street 1:1940 LAURA CIR
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-7009
Practice Address - Country:US
Practice Address - Phone:208-539-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-06
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-396081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical