Healthcare Provider Details

I. General information

NPI: 1730009697
Provider Name (Legal Business Name): SHANA GRAY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 W SILVER SPRING DR
GLENDALE WI
53209-4416
US

IV. Provider business mailing address

1405 W SILVER SPRING DR
GLENDALE WI
53209-4416
US

V. Phone/Fax

Practice location:
  • Phone: 262-450-7901
  • Fax:
Mailing address:
  • Phone: 262-450-7901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number100420771
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number100420771
License Number State
# 3
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: