1154512473 NPI number — MR. GARY STEVEN BRAY M. S,, LMHC

Table of content: MR. GARY STEVEN BRAY M. S,, LMHC (NPI 1154512473)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154512473 NPI number — MR. GARY STEVEN BRAY M. S,, LMHC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRAY
Provider First Name:
GARY
Provider Middle Name:
STEVEN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
M. S,, LMHC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154512473
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/31/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
137 HOSPITAL DR.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WALTON BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32548-5063
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-833-7400
Provider Business Mailing Address Fax Number:
850-833-7528

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
BLACKWATER STOP CAMP
Provider Second Line Business Practice Location Address:
2451 STOP CAMP ROAD
Provider Business Practice Location Address City Name:
MILTON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32570-9111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-957-0995
Provider Business Practice Location Address Fax Number:
850-957-1000
Provider Enumeration Date:
08/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  MH 7729 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 765922900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com