Provider Demographics
NPI:1750849014
Name:MCCRAY, REAGAN RAE
Entity type:Individual
Prefix:
First Name:REAGAN
Middle Name:RAE
Last Name:MCCRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13355 W COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-3970
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:504 GARDENIA DR
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-1408
Practice Address - Country:US
Practice Address - Phone:321-830-4086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-06
Last Update Date:2024-07-16
Deactivation Date:2024-05-20
Deactivation Code:
Reactivation Date:2024-07-15
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-348270106S00000X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No104100000XBehavioral Health & Social Service ProvidersSocial Worker