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General NPI Number Information
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NPI Number | 1720196595
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Entity Type | Individual
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Provider Name | MISTY C RAY BS
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Gender | Female
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Dates
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Enumeration Date | 08/29/2006
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Last Update Date | 09/15/2009
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Provider Practice Location Address
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Address Line | 121 COX ST
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City | BENTON
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State | AR
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Zip | 72015-4611
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Country | US
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Telephone | 501-776-0691
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Fax | 501-776-0692
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Provider Business Mailing Address
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Address Line | 15103 ALEXANDER RD
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City | ALEXANDER
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State | AR
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Zip | 72002-1512
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Country | US
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Telephone | 501-259-6999
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Fax | 501-407-8053
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | SP2352
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License Number State | AR
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