MEDICARE: GRAY MATTERS COUNSELING AND CONSULTING ASSOCIATES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	007492	GA
2	101Y00000X	Counselor	007492	GA
3	101YM0800X	Mental Health Counselor	007492	GA
4	101YP2500X	Professional Counselor	007492	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548782501
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRAY MATTERS COUNSELING AND CONSULTING ASSOCIATES LLC

Provider Business Mailing Address
First Line	:	3645 MARKETPLACE BLVD STE 130-129
Second Line	:
City	:	EAST POINT
State	:	GA
Zip	:	30344-5747
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1341 CLEVELAND AVE
Second Line	:
City	:	EAST POINT
State	:	GA
Zip	:	30344-3425
Country	:	US
Telephone Number	:	770-899-6462
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	CASSAUNDRA GRAY
Credential	:
Telephone Number	:	770-899-6462

Provider Enumeration Date	:	07/12/2017
Last Update Date	:	07/12/2017

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