Healthcare Provider Details

I. General information

NPI: 1952609554
Provider Name (Legal Business Name): RICA MILLER GRAY LPC, NCC, CRC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2011
Last Update Date: 03/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 I 55 N SUITE 220
JACKSON MS
39211-5930
US

IV. Provider business mailing address

PO BOX 16122
JACKSON MS
39236-6122
US

V. Phone/Fax

Practice location:
  • Phone: 601-278-5394
  • Fax: 601-847-5767
Mailing address:
  • Phone: 601-278-5394
  • Fax: 601-362-2815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1411
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: