Provider Demographics
NPI:1932566445
Name:GRAY, DE'ANGELO
Entity type:Individual
Prefix:
First Name:DE'ANGELO
Middle Name:
Last Name:GRAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11111 N HARRELLS FERRY RD
Mailing Address - Street 2:APT 177
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-8389
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11111 N HARRELLS FERRY RD
Practice Address - Street 2:APT 177
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-8389
Practice Address - Country:US
Practice Address - Phone:318-334-9176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-28
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA008849940101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health