Healthcare Provider Details

I. General information

NPI: 1053082230
Provider Name (Legal Business Name): LISA KAREN GRAY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2021
Last Update Date: 09/27/2021
Certification Date: 09/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 WAVERLY AVE UNIT 2
PATCHOGUE NY
11772-1529
US

IV. Provider business mailing address

8 2ND ST
FARMINGVILLE NY
11738-2304
US

V. Phone/Fax

Practice location:
  • Phone: 631-559-3126
  • Fax:
Mailing address:
  • Phone: 631-559-3126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number022244
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: