MEDICARE: MRS. ANNA CARDOSA GRAY PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2251P0200X	Pediatric Physical Therapist	LPT6191	AZ
2	225100000X	Physical Therapist	LPT6191	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	811415	OTHER	AZ	ARIZONA HEATHCARE COST CONTAINMENT SYSTEM (AHCCCS)

General Provider Information

NPI Number	:	1376536250
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ANNA CARDOSA GRAY PT

Provider Business Mailing Address
First Line	:	4948 W PURDUE AVE
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85302-3530
Country	:	US
Telephone Number	:	623-512-6156
Fax Number	:	800-915-4197

Provider Business Practice Location Address
First Line	:	2302 N 15TH AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85007-1201
Country	:	US
Telephone Number	:	623-242-6908
Fax Number	:	623-242-6909

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/25/2005
Last Update Date	:	03/27/2020

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