Provider Demographics
NPI:1093977746
Name:GRAY, STACEY ELIZABETH (LMP)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:ELIZABETH
Last Name:GRAY
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 SE MAIN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-3938
Mailing Address - Country:US
Mailing Address - Phone:888-280-7891
Mailing Address - Fax:
Practice Address - Street 1:725 SE MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-3938
Practice Address - Country:US
Practice Address - Phone:888-280-7891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-25
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR8231225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist