Provider Demographics
NPI:1851455083
Name:GRAY, CANDACE L (MS LPC)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:L
Last Name:GRAY
Suffix:
Gender:F
Credentials:MS LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 835840
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75083-5840
Mailing Address - Country:US
Mailing Address - Phone:972-680-1577
Mailing Address - Fax:972-690-9834
Practice Address - Street 1:4514 TRAVIS ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75205-4112
Practice Address - Country:US
Practice Address - Phone:214-526-0742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXLPCH6915101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX5378LCOtherBLUE CROSS BLUE SHIELD