Provider Demographics
NPI:1093440091
Name:GRAY, LEANORA T (LLC, NCC)
Entity Type:Individual
Prefix:MS
First Name:LEANORA
Middle Name:T
Last Name:GRAY
Suffix:
Gender:F
Credentials:LLC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25400 EDGEMONT DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-2219
Mailing Address - Country:US
Mailing Address - Phone:313-505-6364
Mailing Address - Fax:
Practice Address - Street 1:20411 W. TWELVE MILD RD.
Practice Address - Street 2:ST. #104
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-5414
Practice Address - Country:US
Practice Address - Phone:248-617-7545
Practice Address - Fax:248-856-3801
Is Sole Proprietor?:No
Enumeration Date:2022-07-22
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451022356101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health