Provider Demographics
NPI:1770619413
Name:GRAY, MELLANEY (SLP MS)
Entity type:Individual
Prefix:MS
First Name:MELLANEY
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:SLP MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1902 SEMINARY ST
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-4788
Mailing Address - Country:US
Mailing Address - Phone:618-465-7289
Mailing Address - Fax:
Practice Address - Street 1:12430 TESSON FERRY RD
Practice Address - Street 2:STE. 352
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2702
Practice Address - Country:US
Practice Address - Phone:866-495-5437
Practice Address - Fax:866-495-2445
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006025368235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO463491118Medicaid