Provider Demographics
NPI:1205490927
Name:GRAY, KEVON (PT, DPT)
Entity type:Individual
Prefix:
First Name:KEVON
Middle Name:
Last Name:GRAY
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 PARK OVERLOOK DR
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43085-3661
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2398 WOOD AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43221-3520
Practice Address - Country:US
Practice Address - Phone:614-204-6731
Practice Address - Fax:614-681-0353
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-29
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT017232225100000X
MI5501019115225100000X
COPTL.0016033225100000X
SC8871225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0372137Medicaid