Healthcare Provider Details

I. General information

NPI: 1376489690
Provider Name (Legal Business Name): LATISHA DARCEL GRAY LMFTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2026
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 SE MAYNARD RD STE 204
CARY NC
27511-3615
US

IV. Provider business mailing address

1310 SE MAYNARD RD STE 204
CARY NC
27511-3615
US

V. Phone/Fax

Practice location:
  • Phone: 919-473-6671
  • Fax: 984-272-2850
Mailing address:
  • Phone: 919-473-6671
  • Fax: 984-272-2850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number21094A
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: