Provider Demographics
NPI:1265082499
Name:GRAY, LAURIE A
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:A
Last Name:GRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2609 GLENN HENDREN DR # G100
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-3313
Mailing Address - Country:US
Mailing Address - Phone:816-749-4793
Mailing Address - Fax:
Practice Address - Street 1:2609 GLENN HENDREN DR # G100
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068-3313
Practice Address - Country:US
Practice Address - Phone:816-479-4793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-19
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO225XH1200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2000158034OtherLICENSE