Provider Demographics
NPI:1043684699
Name:PSYCHOLOGICAL COUNSELING THERAPIES,PLLC
Entity type:Organization
Organization Name:PSYCHOLOGICAL COUNSELING THERAPIES,PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:304-676-2808
Mailing Address - Street 1:118 W BURKE ST
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401-3302
Mailing Address - Country:US
Mailing Address - Phone:304-676-2808
Mailing Address - Fax:
Practice Address - Street 1:118 W BURKE ST
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-3302
Practice Address - Country:US
Practice Address - Phone:304-676-2808
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-19
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV1107103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3910006710Medicaid