Healthcare Provider Details

I. General information

NPI: 1720499106
Provider Name (Legal Business Name): JOHN TRENT GRAY MA, LMHC, SUDP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2014
Last Update Date: 05/23/2025
Certification Date: 05/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8059 SE NELSON RD
OLALLA WA
98359
US

IV. Provider business mailing address

8059 SE NELSON RD
OLALLA WA
98359
US

V. Phone/Fax

Practice location:
  • Phone: 360-801-2432
  • Fax:
Mailing address:
  • Phone: 360-801-2432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number60202770
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number61024115
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: