Provider Demographics
NPI:1003012675
Name:GRAY, MICHELLE IRENE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:IRENE
Last Name:GRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:TITUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1920 FOUNTAIN LN
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-4600
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2450 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1450
Practice Address - Country:US
Practice Address - Phone:612-672-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner