Provider Demographics
NPI:1124111422
Name:RAY, AMY (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:RAY
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:HODGIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHYSICAL THERAPIST
Mailing Address - Street 1:1272 FERN AVE
Mailing Address - Street 2:
Mailing Address - City:HARBOR SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49740-9673
Mailing Address - Country:US
Mailing Address - Phone:317-450-1589
Mailing Address - Fax:
Practice Address - Street 1:1272 FERN AVE
Practice Address - Street 2:
Practice Address - City:HARBOR SPRINGS
Practice Address - State:MI
Practice Address - Zip Code:49740-9673
Practice Address - Country:US
Practice Address - Phone:317-450-1589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05007319A225100000X, 2081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200443720Medicaid