Provider Demographics
NPI:1104029321
Name:GRAYSON, KENDALL LEA (MA, LPC)
Entity type:Individual
Prefix:MRS
First Name:KENDALL
Middle Name:LEA
Last Name:GRAYSON
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:KENDALL
Other - Middle Name:LEA
Other - Last Name:ROACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 843966
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64184-3966
Mailing Address - Country:US
Mailing Address - Phone:573-884-3300
Mailing Address - Fax:573-884-0943
Practice Address - Street 1:1125 MADISON ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101-5227
Practice Address - Country:US
Practice Address - Phone:573-632-5000
Practice Address - Fax:573-644-7880
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006026894101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490117009Medicaid
11871325OtherCAQH