Basic Information
| Provider Information | |||||||||
| NPI: | 1629155049 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAY | ||||||||
| FirstName: | TRICIA | ||||||||
| MiddleName: | BETH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.A., CCC-SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1043 | ||||||||
| Address2: | |||||||||
| City: | BOISE CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 739331043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5805171860 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 419 HARDING ST | ||||||||
| Address2: | |||||||||
| City: | CLAYTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 884153323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5753742353 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 11/09/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 3895 | NM | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 5460 | OK | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 4805 | KS | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | SLP6847 | NM | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 09141716 | 01 | ASHA | OTHER |