Provider Demographics
NPI:1588089452
Name:GRAY, CHARLENE
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15702 SEEKERS ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78255-3302
Mailing Address - Country:US
Mailing Address - Phone:210-392-3184
Mailing Address - Fax:
Practice Address - Street 1:1005 E 23RD ST
Practice Address - Street 2:SUITE 200
Practice Address - City:FREMONT
Practice Address - State:NE
Practice Address - Zip Code:68025-0800
Practice Address - Country:US
Practice Address - Phone:866-784-2329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-28
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX114532225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist