Healthcare Provider Details

I. General information

NPI: 1265152672
Provider Name (Legal Business Name): ANGELA MARIE GRAY MS, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2022
Last Update Date: 02/14/2023
Certification Date: 02/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18341 US HIGHWAY 41
LANSE MI
49946-8024
US

IV. Provider business mailing address

18217 2ND SAND BEACH RD
LANSE MI
49946-8358
US

V. Phone/Fax

Practice location:
  • Phone: 906-524-3300
  • Fax:
Mailing address:
  • Phone: 254-592-7395
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6401222843
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: