Provider Demographics
NPI:1346951407
Name:GRAY-VAN BUREN, DONNA
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:GRAY-VAN BUREN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N TRADE ST STE 206
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-9433
Mailing Address - Country:US
Mailing Address - Phone:980-202-2288
Mailing Address - Fax:
Practice Address - Street 1:616 NORTH BROOME STREET
Practice Address - Street 2:SUITE 101
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173
Practice Address - Country:US
Practice Address - Phone:980-202-2288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-09
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA18173101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health