Provider Demographics
NPI:1578991949
Name:GRAY, WYCONDA DENISE (LCSW)
Entity Type:Individual
Prefix:
First Name:WYCONDA
Middle Name:DENISE
Last Name:GRAY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 MEDICAL DR STE AB
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-3361
Mailing Address - Country:US
Mailing Address - Phone:252-335-0803
Mailing Address - Fax:252-331-1796
Practice Address - Street 1:102 MEDICAL DR STE AB
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-3361
Practice Address - Country:US
Practice Address - Phone:252-335-0803
Practice Address - Fax:252-331-1796
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-23
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0101121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical