Provider Demographics
NPI:1922712496
Name:GREY, RODERIC M (MA)
Entity Type:Individual
Prefix:
First Name:RODERIC
Middle Name:M
Last Name:GREY
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 OAKWOOD PLANTATION DR
Mailing Address - Street 2:
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32003-4572
Mailing Address - Country:US
Mailing Address - Phone:904-505-3318
Mailing Address - Fax:
Practice Address - Street 1:124 OAKWOOD PLANTATION DR
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-4572
Practice Address - Country:US
Practice Address - Phone:904-505-3318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-10
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH1859101YM0800X
FLSS598103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health