Provider Demographics
NPI:1609123538
Name:GRAY, AMANDA BALLARD (LPTA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:BALLARD
Last Name:GRAY
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:4704 CAHABA RIVER RD
Practice Address - Street 2:STE J2
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35243-2344
Practice Address - Country:US
Practice Address - Phone:205-298-8711
Practice Address - Fax:205-298-8722
Is Sole Proprietor?:No
Enumeration Date:2012-08-09
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTA6295225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant