Provider Demographics
NPI:1093255713
Name:GRAY, KIMBERLY (LMP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 BROADWAY ST # 270
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98663-3436
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2200 BROADWAY ST
Practice Address - Street 2:SUITE C
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663-3255
Practice Address - Country:US
Practice Address - Phone:503-498-8540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-28
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60575351225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist