Basic Information
| Provider Information | |||||||||
| NPI: | 1851377410 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRAY | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4949 MARBRISA DR | ||||||||
| Address2: | APT #814 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336246372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9496369881 | ||||||||
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| Practice Location | |||||||||
| Address1: | 621 E ALEXANDER ST | ||||||||
| Address2: | |||||||||
| City: | PLANT CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335637126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8137071509 | ||||||||
| FaxNumber: | 8137547864 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2005 | ||||||||
| LastUpdateDate: | 05/26/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 16592 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.