Provider Demographics
NPI:1205337516
Name:GRAY, KEVIN (LPN)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:GRAY
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6601 NE 78TH CT STE A3
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97218-2823
Mailing Address - Country:US
Mailing Address - Phone:503-917-3617
Mailing Address - Fax:
Practice Address - Street 1:10763 SW GREENBURG RD
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-5492
Practice Address - Country:US
Practice Address - Phone:503-684-8159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-22
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201400138LPN101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)