Provider Demographics
NPI:1518439397
Name:GRAY, JUSTIN JAMES (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:JAMES
Last Name:GRAY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 RIVERSIDE CIR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24016-4955
Mailing Address - Country:US
Mailing Address - Phone:540-526-1400
Mailing Address - Fax:
Practice Address - Street 1:3 RIVERSIDE CIR
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-4955
Practice Address - Country:US
Practice Address - Phone:540-526-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-18
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSY.0004960103G00000X
VA0810006204103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist