Provider Demographics
NPI:1629155049
Name:GRAY, TRICIA BETH (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TRICIA
Middle Name:BETH
Last Name:GRAY
Suffix:
Gender:F
Credentials:MA, 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:PO BOX 1043
Mailing Address - Street 2:
Mailing Address - City:BOISE CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73933-1043
Mailing Address - Country:US
Mailing Address - Phone:580-517-1860
Mailing Address - Fax:
Practice Address - Street 1:102 S TEJON ST STE 1100
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-2253
Practice Address - Country:US
Practice Address - Phone:512-377-6318
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106043235Z00000X
OK5460235Z00000X
COSLP.0005849235Z00000X
NMSLP6847235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
09141716OtherASHA