Provider Demographics
NPI:1487677266
Name:GREY, MARK TREVELYAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:TREVELYAN
Last Name:GREY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:980 WESTFALL RD
Mailing Address - Street 2:SUITE 125
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-2605
Mailing Address - Country:US
Mailing Address - Phone:585-292-6630
Mailing Address - Fax:585-292-9720
Practice Address - Street 1:980 WESTFALL RD
Practice Address - Street 2:SUITE 125
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-2605
Practice Address - Country:US
Practice Address - Phone:585-292-6630
Practice Address - Fax:585-292-9720
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY7583103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01085583Medicaid