Healthcare Provider Details

I. General information

NPI: 1114379526
Provider Name (Legal Business Name): MS. BREONA GRAY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2016
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 HIGHFIN DR
WINTER HAVEN FL
33881-9412
US

IV. Provider business mailing address

7901 4TH ST N STE 300
ST PETERSBURG FL
33702-4399
US

V. Phone/Fax

Practice location:
  • Phone: 443-599-9524
  • Fax:
Mailing address:
  • Phone: 443-599-9524
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC16433
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401225281
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC16433
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: