Provider Demographics
NPI:1538744750
Name:GRAY, SYDELLE MARRA (DPT)
Entity type:Individual
Prefix:
First Name:SYDELLE
Middle Name:MARRA
Last Name:GRAY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:SYDELLE
Other - Middle Name:MARRA
Other - Last Name:TOCKMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:201 AUTUMN VIEW CT
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-7343
Mailing Address - Country:US
Mailing Address - Phone:636-485-6390
Mailing Address - Fax:
Practice Address - Street 1:12608 LAMPLIGHTER SQUARE SHOPPING CENTER
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128
Practice Address - Country:US
Practice Address - Phone:314-842-4222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-10
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021006177225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist