Provider Demographics
NPI:1629028675
Name:GRAY, GARY RUSSEL (MA, LMHC)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:RUSSEL
Last Name:GRAY
Suffix:
Gender:M
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2188 EISENHOWER DR
Mailing Address - Street 2:
Mailing Address - City:DUNEDIN
Mailing Address - State:FL
Mailing Address - Zip Code:34698-5633
Mailing Address - Country:US
Mailing Address - Phone:727-421-3014
Mailing Address - Fax:
Practice Address - Street 1:1101 BELCHER RD S
Practice Address - Street 2:SUITE E
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33771-3356
Practice Address - Country:US
Practice Address - Phone:727-421-3014
Practice Address - Fax:727-524-1332
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 2804 FL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL593631612OtherEMPLOYER TAX ID