Provider Demographics
NPI:1164665717
Name:GRAY, CONNIE MARIE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:MARIE
Last Name:GRAY
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2204 A ST
Mailing Address - Street 2:
Mailing Address - City:FOREST GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97116-1624
Mailing Address - Country:US
Mailing Address - Phone:503-799-2306
Mailing Address - Fax:
Practice Address - Street 1:2204 A ST
Practice Address - Street 2:
Practice Address - City:FOREST GROVE
Practice Address - State:OR
Practice Address - Zip Code:97116-1624
Practice Address - Country:US
Practice Address - Phone:503-799-2306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-13
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12222235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist