Provider Demographics
NPI:1205815610
Name:GRAY, CARRIE DIANE (MPT)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:DIANE
Last Name:GRAY
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:DIANE
Other - Last Name:DOERKSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:2475 BOARDWALK
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-6332
Mailing Address - Country:US
Mailing Address - Phone:405-447-1991
Mailing Address - Fax:405-447-1198
Practice Address - Street 1:2340 NW 32ND ST
Practice Address - Street 2:
Practice Address - City:NEWCASTLE
Practice Address - State:OK
Practice Address - Zip Code:73065-6589
Practice Address - Country:US
Practice Address - Phone:405-392-3322
Practice Address - Fax:405-392-3356
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPT3813225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200121360AMedicaid
OK248529505Medicare PIN