Provider Demographics
NPI:1659580132
Name:RAY, VAN DAVID (LCSW)
Entity Type:Individual
Prefix:MR
First Name:VAN
Middle Name:DAVID
Last Name:RAY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 SYME CIR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-9765
Mailing Address - Country:US
Mailing Address - Phone:252-757-2465
Mailing Address - Fax:252-792-1658
Practice Address - Street 1:115 E MAIN ST
Practice Address - Street 2:1ST FLOOR OFFICE 1
Practice Address - City:WILLIAMSTON
Practice Address - State:NC
Practice Address - Zip Code:27892-2492
Practice Address - Country:US
Practice Address - Phone:252-792-1626
Practice Address - Fax:252-792-1658
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2009-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0037221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC139AXOtherBCBS OF NC
NC6003204Medicaid