Provider Demographics
NPI:1407572357
Name:RAY, MICHELE ANN
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:ANN
Last Name:RAY
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 1:2490 BOONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77808-2326
Mailing Address - Country:US
Mailing Address - Phone:936-662-2793
Mailing Address - Fax:
Practice Address - Street 1:2490 BOONVILLE RD
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77808-2326
Practice Address - Country:US
Practice Address - Phone:979-703-1808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-12
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80549101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX80549OtherLPC