Healthcare Provider Details

I. General information

NPI: 1306490313
Provider Name (Legal Business Name): MICHAEL GRAY SLATE LCMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2019
Last Update Date: 05/21/2020
Certification Date: 05/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 S MAIN ST
DOBSON NC
27017-8593
US

IV. Provider business mailing address

701 S MAIN ST
DOBSON NC
27017-8593
US

V. Phone/Fax

Practice location:
  • Phone: 336-356-2600
  • Fax: 336-356-2601
Mailing address:
  • Phone: 336-356-2600
  • Fax: 336-356-2601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number11868
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number11868
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: