Provider Demographics
NPI:1871021998
Name:GRAY, PAIGE (LCSW)
Entity Type:Individual
Prefix:
First Name:PAIGE
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 BREVARD AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32922-7973
Mailing Address - Country:US
Mailing Address - Phone:321-632-5792
Mailing Address - Fax:
Practice Address - Street 1:505 BREVARD AVE STE 106
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32922-7973
Practice Address - Country:US
Practice Address - Phone:321-632-5792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-02
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW11465104100000X
FLSW172761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker