Healthcare Provider Details

I. General information

NPI: 1093806887
Provider Name (Legal Business Name): DONOVAN SEYMOUR GRAY LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 07/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18901 S.W. 197 AVE
MIAMI FL
33187
US

IV. Provider business mailing address

18901 S.W. 197 AVE.
MIAMI FL
33187
US

V. Phone/Fax

Practice location:
  • Phone: 305-282-9226
  • Fax: 305-757-2387
Mailing address:
  • Phone: 305-282-9226
  • Fax: 305-757-4465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberISW3192
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW12589
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: