Provider Demographics
NPI:1598383325
Name:GAY, MICHAEL (MA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GAY
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1762
Mailing Address - Street 2:
Mailing Address - City:LYONS
Mailing Address - State:CO
Mailing Address - Zip Code:80540-1762
Mailing Address - Country:US
Mailing Address - Phone:404-805-2219
Mailing Address - Fax:
Practice Address - Street 1:630 2ND AVE
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:CO
Practice Address - Zip Code:80540-5065
Practice Address - Country:US
Practice Address - Phone:404-805-2219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-08
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONLC.0107582103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
CONLC.0107582OtherLICENSE NUMBER