Provider Demographics
NPI:1427284124
Name:GRAY, ROGER C (LAC, MAC, CCS, ADCII)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:C
Last Name:GRAY
Suffix:
Gender:M
Credentials:LAC, MAC, CCS, ADCII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 WESTMINISTER PL
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29907-1967
Mailing Address - Country:US
Mailing Address - Phone:843-252-2164
Mailing Address - Fax:
Practice Address - Street 1:21 WESTMINSTER PL
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29907-1967
Practice Address - Country:US
Practice Address - Phone:843-252-2164
Practice Address - Fax:843-525-0082
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-08
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1906264101YA0400X
SC96101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)