Provider Demographics
NPI:1346638525
Name:GRAY, SEAN
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:GRAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2729 TERESITA ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-5254
Mailing Address - Country:US
Mailing Address - Phone:619-616-3735
Mailing Address - Fax:
Practice Address - Street 1:27442 PORTOLA PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:FOOTHILL RANCH
Practice Address - State:CA
Practice Address - Zip Code:92610-2823
Practice Address - Country:US
Practice Address - Phone:949-282-5900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-22
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10162225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant