Provider Demographics
NPI:1225209489
Name:RAY, KECIA SPENCER (OTR)
Entity Type:Individual
Prefix:MRS
First Name:KECIA
Middle Name:SPENCER
Last Name:RAY
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1635 BOLING ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39213-4418
Mailing Address - Country:US
Mailing Address - Phone:601-366-0123
Mailing Address - Fax:601-366-0649
Practice Address - Street 1:1635 BOLING ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213-4418
Practice Address - Country:US
Practice Address - Phone:601-366-0123
Practice Address - Fax:601-366-0649
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-17
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT1337174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS9015618Medicaid