Provider Demographics
NPI:1760738306
Name:GRAY, BRIAN LEE (MA MS M DIV RMHCI)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:LEE
Last Name:GRAY
Suffix:
Gender:M
Credentials:MA MS M DIV RMHCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1513 E 9TH ST
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444-2901
Mailing Address - Country:US
Mailing Address - Phone:850-265-1940
Mailing Address - Fax:
Practice Address - Street 1:1513 E 9TH ST
Practice Address - Street 2:
Practice Address - City:LYNN HAVEN
Practice Address - State:FL
Practice Address - Zip Code:32444-2901
Practice Address - Country:US
Practice Address - Phone:850-265-1940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-01
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 13230101YP1600X, 101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMH 13230OtherLICENSED MENTAL HEALTH COUNSELOR