Provider Demographics
NPI:1346593514
Name:GRAY, DEANNA GAIL (PTA)
Entity Type:Individual
Prefix:MRS
First Name:DEANNA
Middle Name:GAIL
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 1:245 AUSTIN DR
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25403-0267
Mailing Address - Country:US
Mailing Address - Phone:443-257-4088
Mailing Address - Fax:
Practice Address - Street 1:80 MADDEX DR
Practice Address - Street 2:
Practice Address - City:SHEPHERDSTOWN
Practice Address - State:WV
Practice Address - Zip Code:25443-4305
Practice Address - Country:US
Practice Address - Phone:304-876-9422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-24
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV001789225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist