Provider Demographics
NPI:1336855535
Name:GRAY, SHAVONNE (MS, LPC)
Entity type:Individual
Prefix:
First Name:SHAVONNE
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1934 OLD GALLOWS RD STE 210
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-4043
Mailing Address - Country:US
Mailing Address - Phone:571-347-3607
Mailing Address - Fax:
Practice Address - Street 1:2741 MONACAN ST APT 302
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-5826
Practice Address - Country:US
Practice Address - Phone:469-713-4464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701012150101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health