Basic Information
Provider Information | |||||||||
NPI: | 1295716504 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RAY | ||||||||
FirstName: | PEGGY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1401 25TH ST S | ||||||||
Address2: | PHYSICAN THERAPY | ||||||||
City: | GREAT FALLS | ||||||||
State: | MT | ||||||||
PostalCode: | 59405 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4067318888 | ||||||||
FaxNumber: | 4067318935 | ||||||||
Practice Location | |||||||||
Address1: | 1401 25TH ST S | ||||||||
Address2: | PHYSICAN THERAPY | ||||||||
City: | GREAT FALLS | ||||||||
State: | MT | ||||||||
PostalCode: | 59405 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4067318888 | ||||||||
FaxNumber: | 4067318935 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/14/2005 | ||||||||
LastUpdateDate: | 03/19/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 800PT | MT | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 0346596 | 05 | MT |   | MEDICAID | 000061656 | 01 | MT | BC | OTHER |