Provider Demographics
NPI:1346993201
Name:GRAY, MARIAH LASHAE (DPT)
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:LASHAE
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 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:866-370-8206
Mailing Address - Fax:517-435-3670
Practice Address - Street 1:5121 RUFE SNOW DR STE 110
Practice Address - Street 2:
Practice Address - City:NORTH RICHLAND HILLS
Practice Address - State:TX
Practice Address - Zip Code:76180-6021
Practice Address - Country:US
Practice Address - Phone:817-345-4367
Practice Address - Fax:254-249-1566
Is Sole Proprietor?:No
Enumeration Date:2022-02-01
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN14034225100000X
GAPT016317225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist