Provider Demographics
NPI:1477510105
Name:GRAY, ANGELA BETH (PTA)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:BETH
Last Name:GRAY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MRS
Other - First Name:ANGELA
Other - Middle Name:BETH
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:17706 INTERSTATE 30 N
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72019-2907
Mailing Address - Country:US
Mailing Address - Phone:501-315-4414
Mailing Address - Fax:
Practice Address - Street 1:17706 INTERSTATE 30 N
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72019-2907
Practice Address - Country:US
Practice Address - Phone:501-315-4414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA1804225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant