Provider Demographics
NPI:1881844009
Name:RAY, LARRY G (LCSW)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:G
Last Name:RAY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 N. CLEVELAND AVENUE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-2713
Mailing Address - Country:US
Mailing Address - Phone:601-835-3306
Mailing Address - Fax:601-835-3342
Practice Address - Street 1:115 N. CLEVELAND AVENUE
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-2713
Practice Address - Country:US
Practice Address - Phone:601-835-3306
Practice Address - Fax:601-835-3342
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-24
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC11411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00123920Medicaid
MS05923703Medicaid