Provider Demographics
NPI:1275638769
Name:GRAY KELLEY, CAROL P (LCPC)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:P
Last Name:GRAY KELLEY
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:
Other - Last Name:GRAY KENNEDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCPC
Mailing Address - Street 1:50 PRIDE STREET
Mailing Address - Street 2:
Mailing Address - City:WESTBROOK
Mailing Address - State:ME
Mailing Address - Zip Code:04092
Mailing Address - Country:US
Mailing Address - Phone:207-712-1971
Mailing Address - Fax:
Practice Address - Street 1:836 MAIN STREET
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092
Practice Address - Country:US
Practice Address - Phone:207-712-1971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC1858103T00000X
MECC15858ME101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103T00000XBehavioral Health & Social Service ProvidersPsychologist