Provider Demographics
NPI:1720554736
Name:GRAY, TRENT R (LCPC)
Entity Type:Individual
Prefix:MR
First Name:TRENT
Middle Name:R
Last Name:GRAY
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2254 N VIEWHILL AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-3794
Mailing Address - Country:US
Mailing Address - Phone:208-401-8229
Mailing Address - Fax:
Practice Address - Street 1:403 W CHERRY LN
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1610
Practice Address - Country:US
Practice Address - Phone:208-887-1911
Practice Address - Fax:208-895-8049
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-17
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-6714101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health