Provider Demographics
NPI:1376676759
Name:STANDARD, WRAY DOUGLAS (BCABA)
Entity Type:Individual
Prefix:MR
First Name:WRAY
Middle Name:DOUGLAS
Last Name:STANDARD
Suffix:
Gender:M
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4117 CASTLEBAY DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-8966
Mailing Address - Country:US
Mailing Address - Phone:904-296-1055
Mailing Address - Fax:904-296-1953
Practice Address - Street 1:4203 SOUTHPOINT BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-6164
Practice Address - Country:US
Practice Address - Phone:904-296-1055
Practice Address - Fax:904-296-1953
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBCABA 0-01-0318101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor