Provider Demographics
NPI:1972527927
Name:GRAYSTONE, GWEN ALANE (PT)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:ALANE
Last Name:GRAYSTONE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:329 W 84TH DR
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-6245
Mailing Address - Country:US
Mailing Address - Phone:219-791-9021
Mailing Address - Fax:219-791-9022
Practice Address - Street 1:329 W 84TH DR
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-6245
Practice Address - Country:US
Practice Address - Phone:219-791-9021
Practice Address - Fax:219-791-9022
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05003950A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN209250CMedicare ID - Type UnspecifiedMEDICARE NUMBER