Provider Demographics
NPI:1639764012
Name:GRAY, SHARON KAY (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:KAY
Last Name:GRAY
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:SHARON
Other - Middle Name:KAY
Other - Last Name:NICKELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:485 N MICHILLINDA AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-2262
Mailing Address - Country:US
Mailing Address - Phone:315-402-5529
Mailing Address - Fax:
Practice Address - Street 1:485 N MICHILLINDA AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-2262
Practice Address - Country:US
Practice Address - Phone:315-402-5529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-07
Last Update Date:2021-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29484235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist