Basic Information
| Provider Information | |||||||||
| NPI: | 1528347846 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAY | ||||||||
| FirstName: | JAMIE | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 60 HIGHWAY 22 WEST | ||||||||
| Address2: | BLANDY WAY OFFICE PARK | ||||||||
| City: | MILLEDGEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310616606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4784512704 | ||||||||
| FaxNumber: | 4784451296 | ||||||||
| Practice Location | |||||||||
| Address1: | 60 HIGHWAY 22 WEST | ||||||||
| Address2: | BLANDY WAY OFFICE PARK | ||||||||
| City: | MILLEDGEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310616606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4784512704 | ||||||||
| FaxNumber: | 4784451296 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2011 | ||||||||
| LastUpdateDate: | 08/04/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 001182 | GA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 001182 | 01 | GA | LMFT | OTHER |