Provider Demographics
NPI:1578741807
Name:GRAY, IRIS (BSOT)
Entity Type:Individual
Prefix:
First Name:IRIS
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:BSOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4245 SUNSET RD
Mailing Address - Street 2:
Mailing Address - City:NESBIT
Mailing Address - State:MS
Mailing Address - Zip Code:38651-9015
Mailing Address - Country:US
Mailing Address - Phone:901-870-1246
Mailing Address - Fax:
Practice Address - Street 1:6569 HIGHWAY 305 N
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-3044
Practice Address - Country:US
Practice Address - Phone:901-870-1246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-08
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
MSOT2144225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist