Provider Demographics
NPI:1689341638
Name:GRAY, BRENNA THERESA MARIE (DC)
Entity Type:Individual
Prefix:
First Name:BRENNA
Middle Name:THERESA MARIE
Last Name:GRAY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 W JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-2336
Mailing Address - Country:US
Mailing Address - Phone:217-342-7222
Mailing Address - Fax:217-342-7214
Practice Address - Street 1:507 W TOWN CENTER BLVD
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-1248
Practice Address - Country:US
Practice Address - Phone:217-954-0424
Practice Address - Fax:217-954-0409
Is Sole Proprietor?:No
Enumeration Date:2021-08-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL38013731111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor