Healthcare Provider Details

I. General information

NPI: 1972527927
Provider Name (Legal Business Name): GWEN ALANE GRAYSTONE P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

329 W 84TH DR
MERRILLVILLE IN
46410-6245
US

IV. Provider business mailing address

329 W 84TH DR
MERRILLVILLE IN
46410-6245
US

V. Phone/Fax

Practice location:
  • Phone: 219-791-9021
  • Fax: 219-791-9022
Mailing address:
  • Phone: 219-791-9021
  • Fax: 219-791-9022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05003950A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: