Provider Demographics
NPI:1346844610
Name:GRAY, MOLLY ARDEN (DPT)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:ARDEN
Last Name:GRAY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:728 N FERDON BLVD STE 3
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-2166
Mailing Address - Country:US
Mailing Address - Phone:850-682-7772
Mailing Address - Fax:
Practice Address - Street 1:728 N FERDON BLVD STE 3
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-2166
Practice Address - Country:US
Practice Address - Phone:850-682-7772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-26
Last Update Date:2020-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT36610225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist