Provider Demographics
NPI:1194080515
Name:GRAYSON, MITCHELL G (LCDC)
Entity type:Individual
Prefix:MR
First Name:MITCHELL
Middle Name:G
Last Name:GRAYSON
Suffix:
Gender:M
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6800
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75608-6800
Mailing Address - Country:US
Mailing Address - Phone:903-758-2471
Mailing Address - Fax:903-234-1639
Practice Address - Street 1:950 N 4TH ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5436
Practice Address - Country:US
Practice Address - Phone:903-758-0596
Practice Address - Fax:903-234-1639
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11574101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)