Provider Demographics
NPI:1912429473
Name:GRAY, COURTNEY LEANNE (ATC)
Entity Type:Individual
Prefix:MISS
First Name:COURTNEY
Middle Name:LEANNE
Last Name:GRAY
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 BROWN AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61103-4102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:319 BROWN AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-4102
Practice Address - Country:US
Practice Address - Phone:815-670-2803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-16
Last Update Date:2017-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer