Provider Demographics
NPI:1245538263
Name:GRAY, KASEY MICHAEL (PTA)
Entity type:Individual
Prefix:MR
First Name:KASEY
Middle Name:MICHAEL
Last Name:GRAY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1481 IOWA AVE W
Mailing Address - Street 2:
Mailing Address - City:FALCON HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55108-2126
Mailing Address - Country:US
Mailing Address - Phone:651-488-9063
Mailing Address - Fax:
Practice Address - Street 1:800 E 28TH ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-3723
Practice Address - Country:US
Practice Address - Phone:612-863-8583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-01
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA370225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant