Healthcare Provider Details

I. General information

NPI: 1275367724
Provider Name (Legal Business Name): GEORGIA CHARLOTTE GRAY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2024
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9053 SHADY GROVE CT
GAITHERSBURG MD
20877-1301
US

IV. Provider business mailing address

9053 SHADY GROVE CT
GAITHERSBURG MD
20877-1301
US

V. Phone/Fax

Practice location:
  • Phone: 240-810-3790
  • Fax:
Mailing address:
  • Phone: 240-810-3790
  • Fax: 240-243-6259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLGPC200001752
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC18358
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: