Provider Demographics
NPI:1396399713
Name:GRAYNER, THERESE R (LPC, LCADC)
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:R
Last Name:GRAYNER
Suffix:
Gender:F
Credentials:LPC, LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 DULLES DR
Mailing Address - Street 2:
Mailing Address - City:DUMONT
Mailing Address - State:NJ
Mailing Address - Zip Code:07628-3600
Mailing Address - Country:US
Mailing Address - Phone:201-732-2646
Mailing Address - Fax:
Practice Address - Street 1:192 3RD AVE STE 4
Practice Address - Street 2:
Practice Address - City:WESTWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07675-2100
Practice Address - Country:US
Practice Address - Phone:201-666-2400
Practice Address - Fax:201-666-2472
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-25
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00195500101YA0400X
NJ37PC00556000101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
861128205OtherRELIEF & SOLUTIONS COUNSELING