Provider Demographics
NPI:1073144176
Name:GRAY, CANDACE HEATHER
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:HEATHER
Last Name:GRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6919 CAMILLE ST
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33437-6057
Mailing Address - Country:US
Mailing Address - Phone:727-667-9491
Mailing Address - Fax:
Practice Address - Street 1:4125 W SAMPLE RD
Practice Address - Street 2:
Practice Address - City:COCONUT CREEK
Practice Address - State:FL
Practice Address - Zip Code:33073-4456
Practice Address - Country:US
Practice Address - Phone:954-968-8333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA8622235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist