Healthcare Provider Details

I. General information

NPI: 1710524145
Provider Name (Legal Business Name): MARTHA A GRAY LPC-S, RPT-S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2019
Last Update Date: 12/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5279 FYLER AVE
SAINT LOUIS MO
63139-1300
US

IV. Provider business mailing address

5279 FYLER AVE
SAINT LOUIS MO
63139-1300
US

V. Phone/Fax

Practice location:
  • Phone: 314-881-2553
  • Fax:
Mailing address:
  • Phone: 314-881-2553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number2012037403
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: