Provider Demographics
NPI:1568089274
Name:GRAYSON, IRVING O JR
Entity Type:Individual
Prefix:MR
First Name:IRVING
Middle Name:O
Last Name:GRAYSON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 N BEECH STREET SUITE 2
Mailing Address - Street 2:
Mailing Address - City:TALLULAH
Mailing Address - State:LA
Mailing Address - Zip Code:71282
Mailing Address - Country:US
Mailing Address - Phone:318-493-5147
Mailing Address - Fax:
Practice Address - Street 1:1555 N. MAIN ST.
Practice Address - Street 2:
Practice Address - City:FAYETTE
Practice Address - State:MS
Practice Address - Zip Code:39069
Practice Address - Country:US
Practice Address - Phone:601-786-8091
Practice Address - Fax:601-786-8023
Is Sole Proprietor?:No
Enumeration Date:2020-06-29
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health