Provider Demographics
NPI:1396035119
Name:GRAY, PHYLLIS ANNE (EDD)
Entity type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:ANNE
Last Name:GRAY
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 E 56TH ST
Mailing Address - Street 2:UNIT 1207
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-1970
Mailing Address - Country:US
Mailing Address - Phone:773-363-5309
Mailing Address - Fax:
Practice Address - Street 1:1700 E 56TH ST
Practice Address - Street 2:UNIT 1207
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1970
Practice Address - Country:US
Practice Address - Phone:773-363-5309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-13
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.001835235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist