Provider Demographics
NPI:1891189437
Name:GRAYSON, DEANDRE (LAT, LMT, ATC, CSCS)
Entity type:Individual
Prefix:
First Name:DEANDRE
Middle Name:
Last Name:GRAYSON
Suffix:
Gender:M
Credentials:LAT, LMT, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5128 E STOP 11 RD STE 36
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-6338
Mailing Address - Country:US
Mailing Address - Phone:317-627-0845
Mailing Address - Fax:
Practice Address - Street 1:5128 E STOP 11 RD STE 36
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-6338
Practice Address - Country:US
Practice Address - Phone:317-627-0845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-21
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN225700000X, 2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist