MEDICARE: LISA GRAY LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	6401014338	MI

General Provider Information

NPI Number	:	1205242161
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA GRAY LPC

Provider Business Mailing Address
First Line	:	2885 W RICK DR
Second Line	:
City	:	PORT HURON
State	:	MI
Zip	:	48060-6532
Country	:	US
Telephone Number	:	810-300-8404
Fax Number	:

Provider Business Practice Location Address
First Line	:	2885 W RICK DR
Second Line	:
City	:	PORT HURON
State	:	MI
Zip	:	48060
Country	:	US
Telephone Number	:	810-300-8404
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/10/2014
Last Update Date	:	07/18/2018

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