Healthcare Provider Details

I. General information

NPI: 1841154804
Provider Name (Legal Business Name): MONTREAVOUS GRAY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 E WASHINGTON AVE STE 400
MADISON WI
53703-4028
US

IV. Provider business mailing address

3819 N 9TH ST
MILWAUKEE WI
53206-3310
US

V. Phone/Fax

Practice location:
  • Phone: 608-344-9494
  • Fax:
Mailing address:
  • Phone: 608-344-9494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code171WV0202X
TaxonomyVehicle Modifications Contractor
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: