Basic Information
| Provider Information | |||||||||
| NPI: | 1265987697 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAY | ||||||||
| FirstName: | SHELBY | ||||||||
| MiddleName: | ELISE | ||||||||
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| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HIGGINS | ||||||||
| OtherFirstName: | SHELBY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2740 COLLEGE AVE | ||||||||
| Address2: | |||||||||
| City: | CONWAY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720346141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013295459 | ||||||||
| FaxNumber: | 5013271738 | ||||||||
| Practice Location | |||||||||
| Address1: | 1540 COUNTRY CLUB RD | ||||||||
| Address2: | |||||||||
| City: | SHERWOOD | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5017535459 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2016 | ||||||||
| LastUpdateDate: | 07/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 4178 | AR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.