Provider Demographics
NPI:1891043675
Name:GRAY, KELLY (LMT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 SHADY BCH
Mailing Address - Street 2:
Mailing Address - City:GENESEO
Mailing Address - State:IL
Mailing Address - Zip Code:61254-9106
Mailing Address - Country:US
Mailing Address - Phone:309-737-5029
Mailing Address - Fax:
Practice Address - Street 1:510 STATE AVE STE 3
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:IL
Practice Address - Zip Code:61256-9690
Practice Address - Country:US
Practice Address - Phone:309-751-9790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-27
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.011622225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist