Provider Demographics
NPI:1699238519
Name:GRAY, KYLEN MATTHEW (PT, DPT)
Entity type:Individual
Prefix:
First Name:KYLEN
Middle Name:MATTHEW
Last Name:GRAY
Suffix:
Gender:M
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 1:3900 CANYON ROCK CT
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47725-8274
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14020 OLD STATE RD
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47725-1121
Practice Address - Country:US
Practice Address - Phone:812-469-4770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-08
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05010536A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist