Provider Demographics
NPI:1265679997
Name:GRAY, MARIE COLETTE (PHD; NCP; LPC;FAAGFS)
Entity Type:Individual
Prefix:MS
First Name:MARIE
Middle Name:COLETTE
Last Name:GRAY
Suffix:
Gender:F
Credentials:PHD; NCP; LPC;FAAGFS
Other - Prefix:MS
Other - First Name:MARIE
Other - Middle Name:COLETTE
Other - Last Name:DOBROWOLSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1172 TWIN STACKS DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:PA
Mailing Address - Zip Code:18612-8505
Mailing Address - Country:US
Mailing Address - Phone:570-674-1505
Mailing Address - Fax:570-674-8679
Practice Address - Street 1:1172 TWIN STACKS DRIVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:PA
Practice Address - Zip Code:18612-9178
Practice Address - Country:US
Practice Address - Phone:570-674-1505
Practice Address - Fax:570-674-8679
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-16
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC003840101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1023153600001OtherDPW