Provider Demographics
NPI:1407144389
Name:GRAY, LILLIAN KATHERINE (AA)
Entity type:Individual
Prefix:
First Name:LILLIAN
Middle Name:KATHERINE
Last Name:GRAY
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 RUTH ST N STE 105
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55119-4409
Mailing Address - Country:US
Mailing Address - Phone:651-447-2118
Mailing Address - Fax:651-447-2120
Practice Address - Street 1:245 RUTH ST N STE 105
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55119-4409
Practice Address - Country:US
Practice Address - Phone:651-447-2118
Practice Address - Fax:651-447-2120
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-13
Last Update Date:2025-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV225400000XMedicaid