Provider Demographics
NPI:1679878995
Name:GRAY, MICHAEL J (PT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:GRAY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 ELMGROVE AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-3451
Mailing Address - Country:US
Mailing Address - Phone:401-490-9780
Mailing Address - Fax:401-783-5570
Practice Address - Street 1:401 ELMGROVE AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-3451
Practice Address - Country:US
Practice Address - Phone:401-490-9780
Practice Address - Fax:401-783-5570
Is Sole Proprietor?:No
Enumeration Date:2011-01-18
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032878-1225100000X
RIPT03377225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist