Provider Demographics
NPI:1235530551
Name:GRAYSON, PETER (LCDP)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:GRAYSON
Suffix:
Gender:M
Credentials:LCDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 BAYBERRY RD
Mailing Address - Street 2:
Mailing Address - City:NARRAGANSETT
Mailing Address - State:RI
Mailing Address - Zip Code:02882-2208
Mailing Address - Country:US
Mailing Address - Phone:917-450-1704
Mailing Address - Fax:
Practice Address - Street 1:600 PUTNAM PIKE
Practice Address - Street 2:SUITE 7
Practice Address - City:GREENVILLE
Practice Address - State:RI
Practice Address - Zip Code:02828-1486
Practice Address - Country:US
Practice Address - Phone:401-949-2220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-05
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RICDP00587101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)