Provider Demographics
NPI:1285758201
Name:GRAY, CONNIE REGINA (LPC)
Entity type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:REGINA
Last Name:GRAY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MRS
Other - First Name:CONNIE
Other - Middle Name:REGINA
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC
Mailing Address - Street 1:700 NE 87TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-4896
Mailing Address - Country:US
Mailing Address - Phone:360-882-2778
Mailing Address - Fax:
Practice Address - Street 1:700 NE 87TH AVE STE 270
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664
Practice Address - Country:US
Practice Address - Phone:360-882-2778
Practice Address - Fax:360-604-1764
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1844101YM0800X
WALH60805339101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health