Provider Demographics
NPI:1205183100
Name:GRAY, HEATHER ANNE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:ANNE
Last Name:GRAY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 STATE ST
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12305-2414
Mailing Address - Country:US
Mailing Address - Phone:518-382-3290
Mailing Address - Fax:
Practice Address - Street 1:504 STATE ST
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12305-2414
Practice Address - Country:US
Practice Address - Phone:518-382-3290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-09
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006424-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant