Provider Demographics
NPI:1639651698
Name:GRAY, VANESSA (LCSW, MCAP)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:LCSW, MCAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 CLEMATIS ST STE 204
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33401-4615
Mailing Address - Country:US
Mailing Address - Phone:561-614-2884
Mailing Address - Fax:
Practice Address - Street 1:319 CLEMATIS ST STE 204
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-4615
Practice Address - Country:US
Practice Address - Phone:561-614-2884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW156711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSW15671OtherFLORIDA DEPARTMENT OF HEALTH