Provider Demographics
NPI:1346329398
Name:GRAY, MARK ROBERT (MA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ROBERT
Last Name:GRAY
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:634 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-6224
Mailing Address - Country:US
Mailing Address - Phone:360-452-2602
Mailing Address - Fax:360-417-0233
Practice Address - Street 1:634 E 8TH ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-6224
Practice Address - Country:US
Practice Address - Phone:360-452-2602
Practice Address - Fax:360-417-0233
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00003702101YM0800X
WALF00001315106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist