Provider Demographics
NPI:1699028522
Name:GRAY, PEGGY L (RMT)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:L
Last Name:GRAY
Suffix:
Gender:F
Credentials:RMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5606 N UNION BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-1940
Mailing Address - Country:US
Mailing Address - Phone:719-243-4586
Mailing Address - Fax:
Practice Address - Street 1:5606 N UNION BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-1940
Practice Address - Country:US
Practice Address - Phone:719-243-4586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-16
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT0008215225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COMT0008215OtherSTATE MASSAGE THERAPY REGISTRATION