Provider Demographics
NPI:1780985812
Name:GRAY, PAUL (PT)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:GRAY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 AMOS RD
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39183-7832
Mailing Address - Country:US
Mailing Address - Phone:601-636-6019
Mailing Address - Fax:601-661-8457
Practice Address - Street 1:151 AMOS RD
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183-7832
Practice Address - Country:US
Practice Address - Phone:601-636-6019
Practice Address - Fax:601-661-8457
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-05
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT3226225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist