Provider Demographics
NPI:1093182339
Name:GRAY, LAURENCE BURTON JR
Entity Type:Individual
Prefix:
First Name:LAURENCE
Middle Name:BURTON
Last Name:GRAY
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-4812
Mailing Address - Country:US
Mailing Address - Phone:405-735-4650
Mailing Address - Fax:
Practice Address - Street 1:400 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-4812
Practice Address - Country:US
Practice Address - Phone:405-735-4650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-21
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK83-0419474OtherOKLAHOMA FAMILY COUNSELING