Provider Demographics
NPI:1891018628
Name:GRAYSON, ANGELA M (LPC, BC-DMT, NCC)
Entity type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:M
Last Name:GRAYSON
Suffix:
Gender:F
Credentials:LPC, BC-DMT, NCC
Other - Prefix:MS
Other - First Name:ANGELA
Other - Middle Name:M
Other - Last Name:TATUM FAIRFAX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC, BC-DMT, NCC
Mailing Address - Street 1:7209 LANCASTER PIKE STE 4-1133
Mailing Address - Street 2:
Mailing Address - City:HOCKESSIN
Mailing Address - State:DE
Mailing Address - Zip Code:19707-9292
Mailing Address - Country:US
Mailing Address - Phone:888-440-2712
Mailing Address - Fax:888-440-2712
Practice Address - Street 1:222 PHILADELPHIA PIKE STE 7
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19809-3166
Practice Address - Country:US
Practice Address - Phone:888-440-2712
Practice Address - Fax:888-440-2712
Is Sole Proprietor?:No
Enumeration Date:2010-03-08
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC005056101YP2500X
MDBC-DMT 1008225600000X
DEPC0000438101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance Therapist