Provider Demographics
NPI:1194049916
Name:GRAY, KENTON ANDREW (BS, MC, LPC)
Entity type:Individual
Prefix:MR
First Name:KENTON
Middle Name:ANDREW
Last Name:GRAY
Suffix:
Gender:M
Credentials:BS, MC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6731 N WATERLILLY AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83714
Mailing Address - Country:US
Mailing Address - Phone:208-608-9132
Mailing Address - Fax:
Practice Address - Street 1:6731 N WATERLILLY WAY
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83714-4043
Practice Address - Country:US
Practice Address - Phone:208-608-9132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-23
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-3735101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional