Provider Demographics
NPI:1124674742
Name:GRAY, AMELIA ANNE (PT, DPT)
Entity type:Individual
Prefix:
First Name:AMELIA
Middle Name:ANNE
Last Name:GRAY
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12250 EL CAMINO REAL STE 190
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-2298
Mailing Address - Country:US
Mailing Address - Phone:770-328-2304
Mailing Address - Fax:
Practice Address - Street 1:12250 EL CAMINO REAL STE 190
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-2298
Practice Address - Country:US
Practice Address - Phone:858-793-1460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-12
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA301562225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA301562OtherPHYSICAL THERAPY BOARD OF CALIFORNIA