Provider Demographics
NPI:1376392225
Name:GRAY, RICHARD LEE (PMHNP)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:LEE
Last Name:GRAY
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 STONE PL
Mailing Address - Street 2:
Mailing Address - City:SCOTT DEPOT
Mailing Address - State:WV
Mailing Address - Zip Code:25560-9466
Mailing Address - Country:US
Mailing Address - Phone:304-575-7877
Mailing Address - Fax:
Practice Address - Street 1:1 KENTON DR STE 200
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25311-1256
Practice Address - Country:US
Practice Address - Phone:304-408-3292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-14
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV99336363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health