Provider Demographics
NPI:1265195713
Name:GRAY, BREANN MICHELE (LPC)
Entity type:Individual
Prefix:
First Name:BREANN
Middle Name:MICHELE
Last Name:GRAY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:BREANN
Other - Middle Name:MICHELE
Other - Last Name:BRIDGES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:301 HILLSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:IL
Mailing Address - Zip Code:61350-1021
Mailing Address - Country:US
Mailing Address - Phone:815-993-0836
Mailing Address - Fax:
Practice Address - Street 1:920 WEST ST STE 116
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-2765
Practice Address - Country:US
Practice Address - Phone:815-780-3696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor