Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225X00000X | Occupational Therapist | MO | |
Y | 225XH1200X | Occupational Therapist - Hand | MO |
NPI | 1265082499 |
---|---|
Provider Name | Laurie A Gray |
First Address | Liberty, MO 64068-3313 |
Second Address | Liberty, MO 64068-3313 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/09/2019 |
Last Update Date | 19/09/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2000158034 | LICENSE (01) | MO |