Provider Demographics
NPI:1467792317
Name:GRAY, SAMUEL CLYDE (MA, LMHC)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:CLYDE
Last Name:GRAY
Suffix:
Gender:M
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 COUNTY ROAD 17A N
Mailing Address - Street 2:LOT 64
Mailing Address - City:AVON PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33825-7739
Mailing Address - Country:US
Mailing Address - Phone:863-257-2533
Mailing Address - Fax:
Practice Address - Street 1:2523 US HIGHWAY 27 S
Practice Address - Street 2:SUITE 130
Practice Address - City:AVON PARK
Practice Address - State:FL
Practice Address - Zip Code:33825-7744
Practice Address - Country:US
Practice Address - Phone:863-452-0710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-28
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 11620101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health