Provider Demographics
NPI:1396920120
Name:GRAY, JUSTIN J (DPT, ATC,CSCS)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:J
Last Name:GRAY
Suffix:
Gender:M
Credentials:DPT, ATC,CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 EAGAN AVE
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23665-1921
Mailing Address - Country:US
Mailing Address - Phone:913-940-0436
Mailing Address - Fax:
Practice Address - Street 1:73 NEALY BLVD
Practice Address - Street 2:BLDG 256
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23665-2023
Practice Address - Country:US
Practice Address - Phone:913-940-0436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-28
Last Update Date:2009-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist