Provider Demographics
NPI:1154314417
Name:GRABER, GAIL RUST (MA AUDIOLOGY)
Entity Type:Individual
Prefix:
First Name:GAIL
Middle Name:RUST
Last Name:GRABER
Suffix:
Gender:F
Credentials:MA AUDIOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 W TOKAY ST
Mailing Address - Street 2:STE 4
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-3808
Mailing Address - Country:US
Mailing Address - Phone:209-368-9222
Mailing Address - Fax:209-368-4662
Practice Address - Street 1:1101 W TOKAY ST
Practice Address - Street 2:STE 4
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-3808
Practice Address - Country:US
Practice Address - Phone:209-368-9222
Practice Address - Fax:209-368-4662
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU570237600000X
CAHA1149237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAU0005700Medicaid
CAAU0005700Medicaid