Provider Demographics
NPI:1245058890
Name:GRAY, KATIE (MS)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:935 E WINDING CREEK DRIVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616
Mailing Address - Country:US
Mailing Address - Phone:208-938-4748
Mailing Address - Fax:208-938-1710
Practice Address - Street 1:935 E WINDING CREEK DRIVE
Practice Address - Street 2:SUITE 120
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616
Practice Address - Country:US
Practice Address - Phone:208-938-4748
Practice Address - Fax:208-938-1710
Is Sole Proprietor?:No
Enumeration Date:2024-10-02
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID8461379235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist