Provider Demographics
NPI:1104372440
Name:GRAY, TRAVIS
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:GRAY
Suffix:
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 1:3640 N. FEDERAL HWY B3 #128
Mailing Address - Street 2:
Mailing Address - City:LIGHTHOUSE POINT
Mailing Address - State:FL
Mailing Address - Zip Code:33064
Mailing Address - Country:US
Mailing Address - Phone:954-599-8946
Mailing Address - Fax:
Practice Address - Street 1:3640 N FEDERAL HWY STE B3
Practice Address - Street 2:
Practice Address - City:LIGHTHOUSE POINT
Practice Address - State:FL
Practice Address - Zip Code:33064-6648
Practice Address - Country:US
Practice Address - Phone:954-599-8946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-28
Last Update Date:2016-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH13085101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health