Provider Demographics
NPI:1235483124
Name:GRAY, LAUREN TABOR (PHD, CCC-SLP)
Entity Type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:TABOR
Last Name:GRAY
Suffix:
Gender:F
Credentials:PHD, CCC-SLP
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:CHRISTINE
Other - Last Name:TABOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7595 SW 33RD ST
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33314-7708
Mailing Address - Country:US
Mailing Address - Phone:954-262-8963
Mailing Address - Fax:
Practice Address - Street 1:7595 SW 33RD ST
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33314-7708
Practice Address - Country:US
Practice Address - Phone:954-262-8963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-31
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA12486235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS00WDOtherBLUE CROSS BLUE SHIELD
FL007196300Medicaid
FLGT240ZMedicare PIN