Provider Demographics
NPI:1174921449
Name:GREY, VICTORIA LYNN (DPT)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:LYNN
Last Name:GREY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:LYNN
Other - Last Name:MARTINEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5060 CASCADE RD SE STE A
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3808
Mailing Address - Country:US
Mailing Address - Phone:616-954-0950
Mailing Address - Fax:616-954-1728
Practice Address - Street 1:5060 CASCADE RD SE STE A
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3808
Practice Address - Country:US
Practice Address - Phone:616-954-0950
Practice Address - Fax:616-954-1728
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-18
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225100000X
MI5501019755225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist