Provider Demographics
NPI:1649636077
Name:GRAY, DAVID STEPHEN (LCPC)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:STEPHEN
Last Name:GRAY
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22072 W ENGLE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLA
Mailing Address - State:IL
Mailing Address - Zip Code:60046-5411
Mailing Address - Country:US
Mailing Address - Phone:440-714-8822
Mailing Address - Fax:
Practice Address - Street 1:20854 W GENOA AVE
Practice Address - Street 2:
Practice Address - City:LAKE VILLA
Practice Address - State:IL
Practice Address - Zip Code:60046-8957
Practice Address - Country:US
Practice Address - Phone:440-714-8822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-14
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178011708101YP2500X
IL180011813101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional