Provider Demographics
NPI:1265695100
Name:MCINTOSH-GRAY, CAMILLE MARIE (PT)
Entity type:Individual
Prefix:
First Name:CAMILLE
Middle Name:MARIE
Last Name:MCINTOSH-GRAY
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 1:10700 MEDLOCK BRIDGE RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-8456
Mailing Address - Country:US
Mailing Address - Phone:770-623-0105
Mailing Address - Fax:
Practice Address - Street 1:1430 FIVE FORKS TRICKUM RD
Practice Address - Street 2:SUITE 210
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-8182
Practice Address - Country:US
Practice Address - Phone:678-377-1738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-09
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT009283225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist