Provider Demographics
NPI:1336611946
Name:GRAY, AMY ELIZABETH (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:ELIZABETH
Last Name:GRAY
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:MISS
Other - First Name:AMY
Other - Middle Name:E
Other - Last Name:BANKERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:11200 SHERADALE DR
Mailing Address - Street 2:
Mailing Address - City:KINGSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21087-1404
Mailing Address - Country:US
Mailing Address - Phone:443-617-5859
Mailing Address - Fax:
Practice Address - Street 1:120 PYLESVILLE RD
Practice Address - Street 2:
Practice Address - City:PYLESVILLE
Practice Address - State:MD
Practice Address - Zip Code:21132-1305
Practice Address - Country:US
Practice Address - Phone:443-617-5859
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-20
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD04410235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD04410Medicaid