Provider Demographics
NPI:1891189437
Name:GRAYSON, DEANDRE (LAT, ATC, LMT, CES)
Entity Type:Individual
Prefix:
First Name:DEANDRE
Middle Name:
Last Name:GRAYSON
Suffix:
Gender:M
Credentials:LAT, ATC, LMT, CES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7334 E 34TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46226-6238
Mailing Address - Country:US
Mailing Address - Phone:317-627-0845
Mailing Address - Fax:
Practice Address - Street 1:1400 E HANNA AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227
Practice Address - Country:US
Practice Address - Phone:317-627-0845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-21
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN2255A2300X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist