Provider Demographics
NPI:1932699089
Name:GRAY, KEVIN JR
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:GRAY
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 W OLYMPIC BLVD STE 106-1027
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-6500
Mailing Address - Country:US
Mailing Address - Phone:323-545-0088
Mailing Address - Fax:
Practice Address - Street 1:3003 W OLYMPIC BLVD STE 106-1027
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-6500
Practice Address - Country:US
Practice Address - Phone:323-545-0088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-15
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11748225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist