Provider Demographics
NPI:1407157274
Name:GRAY, ELVA (PTA)
Entity Type:Individual
Prefix:
First Name:ELVA
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 ROWLETT RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75043-3700
Mailing Address - Country:US
Mailing Address - Phone:972-303-7021
Mailing Address - Fax:972-303-7020
Practice Address - Street 1:545 ROWLETT RD
Practice Address - Street 2:SUITE A
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75043-3700
Practice Address - Country:US
Practice Address - Phone:972-303-7021
Practice Address - Fax:972-303-7020
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-10
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2003364225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX207164901Medicaid
TX149984001Medicaid
TX676535Medicare PIN
TX149984001Medicaid