Provider Demographics
NPI:1902404635
Name:GRAY, AUSTIN CHARLES MYLES (DPT)
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:CHARLES MYLES
Last Name:GRAY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10416 GAVIOTA AVE
Mailing Address - Street 2:
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344-7016
Mailing Address - Country:US
Mailing Address - Phone:818-903-0096
Mailing Address - Fax:
Practice Address - Street 1:6815 NOBLE AVE
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-3796
Practice Address - Country:US
Practice Address - Phone:818-901-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT298933225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist