Healthcare Provider Details

I. General information

NPI: 1902389695
Provider Name (Legal Business Name): AMY GRAY PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2018
Last Update Date: 09/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 DEVELOPMENT BLVD
WACO TX
76705-2903
US

IV. Provider business mailing address

35 SUGAR CREEK PL
WACO TX
76712-3407
US

V. Phone/Fax

Practice location:
  • Phone: 254-296-8976
  • Fax:
Mailing address:
  • Phone: 254-498-3815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2112657
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: