Provider Demographics
NPI:1639336332
Name:GRAY STANLEY, TOMMI MICHELLE (MS CCC-A)
Entity Type:Individual
Prefix:
First Name:TOMMI
Middle Name:MICHELLE
Last Name:GRAY STANLEY
Suffix:
Gender:F
Credentials:MS CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 2ND AVE N STE 102
Mailing Address - Street 2:
Mailing Address - City:NORTH MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29582-3287
Mailing Address - Country:US
Mailing Address - Phone:843-732-6090
Mailing Address - Fax:843-491-3573
Practice Address - Street 1:1016 2ND AVE N STE 102
Practice Address - Street 2:
Practice Address - City:NORTH MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29582-3287
Practice Address - Country:US
Practice Address - Phone:843-732-6090
Practice Address - Fax:843-491-3573
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-20
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3410231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA1158Medicaid