Provider Demographics
NPI:1396406237
Name:GRAY, DEREK ALLEN (PTA)
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:ALLEN
Last Name:GRAY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 S FINANCIAL PL APT 1703
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-1794
Mailing Address - Country:US
Mailing Address - Phone:804-317-7849
Mailing Address - Fax:
Practice Address - Street 1:2425 E 71ST ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649-2612
Practice Address - Country:US
Practice Address - Phone:773-721-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-03
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.009402225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant