Healthcare Provider Details

I. General information

NPI: 1104167113
Provider Name (Legal Business Name): NICOLE MARIE GRAY LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2013
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7541 MENTOR AVE # A104
MENTOR OH
44060-5431
US

IV. Provider business mailing address

6700 BETA DR SUITE 301
MAYFIELD VILLAGE OH
44143-2363
US

V. Phone/Fax

Practice location:
  • Phone: 440-968-6341
  • Fax: 440-431-3830
Mailing address:
  • Phone: 440-446-9696
  • Fax: 440-449-1435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE.0004187
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: