Provider Demographics
NPI:1750589081
Name:GRAY, SHANNA RAE (RPT)
Entity type:Individual
Prefix:MRS
First Name:SHANNA
Middle Name:RAE
Last Name:GRAY
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4010 BLAINE RD
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-1626
Mailing Address - Country:US
Mailing Address - Phone:405-833-2749
Mailing Address - Fax:
Practice Address - Street 1:4010 BLAINE RD
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-1626
Practice Address - Country:US
Practice Address - Phone:405-833-2749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPT18012251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics