Provider Demographics
NPI:1629556006
Name:GRAY, MADISON LUCILLE (OTRL)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:LUCILLE
Last Name:GRAY
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:MADISON
Other - Middle Name:LUCILLE
Other - Last Name:TREMPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3707 KATALIN CT
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48706-2161
Mailing Address - Country:US
Mailing Address - Phone:989-671-0866
Mailing Address - Fax:989-671-0867
Practice Address - Street 1:3707 KATALIN CT
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706-2161
Practice Address - Country:US
Practice Address - Phone:989-671-0866
Practice Address - Fax:989-671-0867
Is Sole Proprietor?:No
Enumeration Date:2018-07-30
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI5201012830225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician