Provider Demographics
NPI:1598432536
Name:GRAY, TIMOTHY DENNIS
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:DENNIS
Last Name:GRAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 RIDGEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07040-1127
Mailing Address - Country:US
Mailing Address - Phone:973-908-2504
Mailing Address - Fax:
Practice Address - Street 1:239 MILLBURN AVE
Practice Address - Street 2:
Practice Address - City:MILLBURN
Practice Address - State:NJ
Practice Address - Zip Code:07041-1718
Practice Address - Country:US
Practice Address - Phone:862-308-0222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA02028200225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist