Provider Demographics
NPI:1053329557
Name:GRAY, NICOLE (PT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 SCENERY DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:PA
Mailing Address - Zip Code:15037-2000
Mailing Address - Country:US
Mailing Address - Phone:412-751-0040
Mailing Address - Fax:412-751-0041
Practice Address - Street 1:605 SCENERY DR
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:PA
Practice Address - Zip Code:15037-2000
Practice Address - Country:US
Practice Address - Phone:412-751-0040
Practice Address - Fax:412-751-0041
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC004406L225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015935850004Medicaid
PA0015935850004Medicaid