Provider Demographics
NPI:1306081914
Name:GRAY, KESHELL ANTRON (MS, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:KESHELL
Middle Name:ANTRON
Last Name:GRAY
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:197 IRA RD
Mailing Address - Street 2:
Mailing Address - City:MOUND BAYOU
Mailing Address - State:MS
Mailing Address - Zip Code:38762-9708
Mailing Address - Country:US
Mailing Address - Phone:662-741-2185
Mailing Address - Fax:
Practice Address - Street 1:7160 TCHULAHOMA RD
Practice Address - Street 2:BLDG. B SUITE 4
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9266
Practice Address - Country:US
Practice Address - Phone:662-349-2733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-10
Last Update Date:2018-09-08
Deactivation Date:2018-08-24
Deactivation Code:
Reactivation Date:2018-09-08
Provider Licenses
StateLicense IDTaxonomies
MSS3231235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015269Medicaid