Provider Demographics
NPI:1508277104
Name:WRAY, MICHELLE (PTA, ATC, LAT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:WRAY
Suffix:
Gender:F
Credentials:PTA, ATC, LAT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:ROSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:212 W CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-1552
Mailing Address - Country:US
Mailing Address - Phone:615-478-2862
Mailing Address - Fax:
Practice Address - Street 1:212 W CEDAR ST
Practice Address - Street 2:
Practice Address - City:GOODLETTSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37072-1552
Practice Address - Country:US
Practice Address - Phone:615-478-2862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-16
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5540225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant