Provider Demographics
NPI:1366829137
Name:RHONDA LANE GRAY THERAPY SERVICES,INC.
Entity Type:Organization
Organization Name:RHONDA LANE GRAY THERAPY SERVICES,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:LANE
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:MACCC SLP
Authorized Official - Phone:706-833-7376
Mailing Address - Street 1:1036 BARRETT DR
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-4029
Mailing Address - Country:US
Mailing Address - Phone:706-833-7376
Mailing Address - Fax:
Practice Address - Street 1:601 N BELAIR SQ
Practice Address - Street 2:#19
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-4321
Practice Address - Country:US
Practice Address - Phone:706-833-7376
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-30
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP004870261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
11885042OtherCAQH
GA000897993Medicaid
GA01900609OtherAMERIGROUP