Provider Demographics
NPI:1346784691
Name:GRAYTON, TERRY (CASAC 26767)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:GRAYTON
Suffix:
Gender:M
Credentials:CASAC 26767
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 BRIELLE AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6427
Mailing Address - Country:US
Mailing Address - Phone:718-816-6589
Mailing Address - Fax:
Practice Address - Street 1:460 BRIELLE AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-6427
Practice Address - Country:US
Practice Address - Phone:718-816-6589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-06
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY26767101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)