Provider Demographics
NPI:1396757456
Name:BRAY, HOLLY A (PT)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:A
Last Name:BRAY
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 1:10470 OLD PLACERVILLE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:855-771-0335
Mailing Address - Fax:
Practice Address - Street 1:3 MEDICAL PLAZA DR
Practice Address - Street 2:SUITE 100
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3087
Practice Address - Country:US
Practice Address - Phone:916-781-5188
Practice Address - Fax:916-781-5187
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT22026225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT0220260Medicaid
0PT220260Medicare ID - Type Unspecified
Q59039Medicare UPIN
CA0PT220261Medicare PIN