Provider Demographics
NPI:1275777310
Name:GRAY, CARRIE MARIE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:MARIE
Last Name:GRAY
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 VIA DI PARIONE CT
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89011-0811
Mailing Address - Country:US
Mailing Address - Phone:870-723-2833
Mailing Address - Fax:
Practice Address - Street 1:580 VIA DI PARIONE CT
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89011-0811
Practice Address - Country:US
Practice Address - Phone:870-723-2833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-20
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6076235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1275777310Medicaid