Provider Demographics
NPI:1275193518
Name:GRAY, REBECCA (OTD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:UPCHURCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:810 FANSHAWE LN APT 100
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-3433
Mailing Address - Country:US
Mailing Address - Phone:765-960-2407
Mailing Address - Fax:
Practice Address - Street 1:1701 S CREASY LN
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4972
Practice Address - Country:US
Practice Address - Phone:800-654-9410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-18
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31006897A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist