Provider Demographics
NPI:1689376766
Name:WRAY, ANDRE D
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:D
Last Name:WRAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13320 PIKE LAKE DRIVE
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-4039
Mailing Address - Country:US
Mailing Address - Phone:813-819-1910
Mailing Address - Fax:
Practice Address - Street 1:13320 PIKE LAKE DRIVE
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33579-4039
Practice Address - Country:US
Practice Address - Phone:813-819-1910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-21
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 320800000X, 101Y00000X
FL251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251B00000XAgenciesCase Management
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness