Provider Demographics
NPI:1386763795
Name:GRAY, CAROL ANNE (LMT, MIDWIFE)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:ANNE
Last Name:GRAY
Suffix:
Gender:F
Credentials:LMT, MIDWIFE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 NW 53RD DRIVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210
Mailing Address - Country:US
Mailing Address - Phone:503-236-2999
Mailing Address - Fax:503-236-4334
Practice Address - Street 1:1414 NW 53RD DRIVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210
Practice Address - Country:US
Practice Address - Phone:503-236-2999
Practice Address - Fax:503-236-4334
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175M00000X
OR3150225700000X
WAMA00004670225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered175M00000XOther Service ProvidersMidwife, Lay
Not Answered225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist