Provider Demographics
NPI:1811029671
Name:GRAY, WANDA LUE (CCC-S)
Entity Type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:LUE
Last Name:GRAY
Suffix:
Gender:F
Credentials:CCC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8827 N 66TH AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85302-4382
Mailing Address - Country:US
Mailing Address - Phone:623-842-8240
Mailing Address - Fax:
Practice Address - Street 1:4932 W MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-2122
Practice Address - Country:US
Practice Address - Phone:623-842-8240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP0721235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ801995Medicaid