Healthcare Provider Details

I. General information

NPI: 1952551590
Provider Name (Legal Business Name): DIANA C GRAY PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2008
Last Update Date: 06/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11135 MANCHESTER RD
SAINT LOUIS MO
63122-1253
US

IV. Provider business mailing address

11135 MANCHESTER RD
SAINT LOUIS MO
63122-1253
US

V. Phone/Fax

Practice location:
  • Phone: 314-822-4400
  • Fax: 314-822-4111
Mailing address:
  • Phone: 314-822-4400
  • Fax: 314-822-4111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number01329
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: