Healthcare Provider Details

I. General information

NPI: 1770495509
Provider Name (Legal Business Name): SUNNY GRACE MAYALL PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6048 W HIGHWAY 74
INDIAN TRAIL NC
28079-3591
US

IV. Provider business mailing address

2630 SOUTH BLVD APT 133
CHARLOTTE NC
28209-1175
US

V. Phone/Fax

Practice location:
  • Phone: 980-993-5540
  • Fax:
Mailing address:
  • Phone: 803-260-5449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberP25272
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: