MEDICARE: MRS. TERESA LYNN GRAY M.A. CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	50972-02	SD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	50972-02	OTHER	SD	SD-DOE
2	01106843	OTHER	SD	ASHA

General Provider Information

NPI Number	:	1275721474
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TERESA LYNN GRAY M.A. CCC-SLP

Provider Business Mailing Address
First Line	:	7110 JORDAN DR
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57702-8738
Country	:	US
Telephone Number	:	605-342-4412
Fax Number	:	605-342-4211

Provider Business Practice Location Address
First Line	:	7110 JORDAN DR
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57702-8738
Country	:	US
Telephone Number	:	605-342-4412
Fax Number	:	605-342-4211

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/12/2007
Last Update Date	:	10/12/2007

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