Provider Demographics
NPI:1902389695
Name:GRAY, AMY (PTA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 SUGAR CREEK PL
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-3407
Mailing Address - Country:US
Mailing Address - Phone:254-498-3815
Mailing Address - Fax:
Practice Address - Street 1:2401 DEVELOPMENT BLVD
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76705-2903
Practice Address - Country:US
Practice Address - Phone:254-296-8976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2112657225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant