Healthcare Provider Details

I. General information

NPI: 1053755751
Provider Name (Legal Business Name): LISA B GRAY OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2013
Last Update Date: 04/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13550 S OUTER HWY FORTY
CHESTERFIELD MO
63017
US

IV. Provider business mailing address

205 MORNING DEW CT
SAINT PETERS MO
63376-3864
US

V. Phone/Fax

Practice location:
  • Phone: 314-878-1330
  • Fax:
Mailing address:
  • Phone: 636-294-4104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2000155690
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: