Provider Demographics
NPI:1497768139
Name:PETRAY, PAMELA K (MA CCCSLP)
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:K
Last Name:PETRAY
Suffix:
Gender:F
Credentials:MA CCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18036 SUNSET RD
Mailing Address - Street 2:
Mailing Address - City:WINSLOW
Mailing Address - State:AR
Mailing Address - Zip Code:72959
Mailing Address - Country:US
Mailing Address - Phone:479-267-4673
Mailing Address - Fax:
Practice Address - Street 1:91 NEAL ST
Practice Address - Street 2:HOPE FOR TOMORROW
Practice Address - City:FARMINGTON
Practice Address - State:AR
Practice Address - Zip Code:72730
Practice Address - Country:US
Practice Address - Phone:479-267-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP1442235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5X943OtherBCBS