Provider Demographics
NPI:1235552738
Name:GRAY, HEATHER (LMP)
Entity Type:Individual
Prefix:
First Name:HEATHER
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 1:15202 NE 181ST LOOP
Mailing Address - Street 2:
Mailing Address - City:BRUSH PRAIRIE
Mailing Address - State:WA
Mailing Address - Zip Code:98606-9669
Mailing Address - Country:US
Mailing Address - Phone:702-704-3853
Mailing Address - Fax:
Practice Address - Street 1:16703 SE MCGILLIVRAY BLVD STE 215
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-4301
Practice Address - Country:US
Practice Address - Phone:360-883-2450
Practice Address - Fax:866-935-1910
Is Sole Proprietor?:No
Enumeration Date:2014-02-04
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60432531225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist