Provider Demographics
NPI:1407090764
Name:GRAY, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3512 169TH STREET CT E
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98446-2923
Mailing Address - Country:US
Mailing Address - Phone:253-970-2637
Mailing Address - Fax:
Practice Address - Street 1:325 N SAINT PAUL ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75201-3801
Practice Address - Country:US
Practice Address - Phone:866-953-0011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-29
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00004076225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist