Provider Demographics
NPI:1376175570
Name:GRAY, DAVID (CACP)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:GRAY
Suffix:
Gender:M
Credentials:CACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 BOARDWALK DR STE A
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:SC
Mailing Address - Zip Code:29936-7994
Mailing Address - Country:US
Mailing Address - Phone:843-645-2770
Mailing Address - Fax:843-645-2771
Practice Address - Street 1:124 BOARDWALK DR STE A
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:SC
Practice Address - Zip Code:29936-7994
Practice Address - Country:US
Practice Address - Phone:843-645-2770
Practice Address - Fax:843-645-2771
Is Sole Proprietor?:No
Enumeration Date:2020-02-06
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1760596746Medicaid