Provider Demographics
NPI:1316538184
Name:GRAY, BRIAN D (LMT)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:D
Last Name:GRAY
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 JEFFERSON BLVD STE 4
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02888-3847
Mailing Address - Country:US
Mailing Address - Phone:401-423-4433
Mailing Address - Fax:
Practice Address - Street 1:222 JEFFERSON BLVD STE 4
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02888-3847
Practice Address - Country:US
Practice Address - Phone:401-423-4433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-03
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMT01704225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIMT01704OtherRHODE ISLAND DEPARTMENT OF HEALTH