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General NPI Number Information
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NPI Number | 1831561554
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Entity Type | Organization
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Legal Business Name | GRAY PSYCHOLOGICAL SERVICES LLC
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Dates
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Enumeration Date | 10/21/2015
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Last Update Date | 02/26/2016
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Provider Practice Location Address
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Address Line | 402 B W. MT. VERNON STREET STE 337
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City | NIXA
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State | MO
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Zip | 65714
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Country | US
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Telephone | 816-813-6934
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Fax |
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Provider Business Mailing Address
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Address Line | 402 B W. MT. VERNON STREET STE 337
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City | NIXA
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State | MO
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Zip | 65714
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Country | US
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Telephone | 816-813-6934
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. BRYCE T. GRAY
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Credential | PSYD
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Telephone | 816-813-6934
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 2013040380
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License Number State | MO
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