Provider Demographics
NPI:1912067067
Name:DE GRUYL, LEX (COUNSELOR PSYCHOLO)
Entity type:Individual
Prefix:
First Name:LEX
Middle Name:
Last Name:DE GRUYL
Suffix:
Gender:M
Credentials:COUNSELOR PSYCHOLO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 WINDY RUN RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE BIRCH
Mailing Address - State:WV
Mailing Address - Zip Code:26629-9502
Mailing Address - Country:US
Mailing Address - Phone:304-765-5919
Mailing Address - Fax:
Practice Address - Street 1:240 WINDY RUN RD
Practice Address - Street 2:
Practice Address - City:LITTLE BIRCH
Practice Address - State:WV
Practice Address - Zip Code:26629-9502
Practice Address - Country:US
Practice Address - Phone:304-765-5919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21003101YP2500X
WV1124101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0164362000Medicaid