Basic Information
| Provider Information | |||||||||
| NPI: | 1699735621 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAY | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16083 SW UPPER BOONES FERRY RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | TIGARD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972247736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002198835 | ||||||||
| FaxNumber: | 5036399699 | ||||||||
| Practice Location | |||||||||
| Address1: | 6821 N COUNTRY HOMES BLVD | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992084372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5093256776 | ||||||||
| FaxNumber: | 5093250817 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 02/17/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 00005470 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0038860 | 01 | WA | STATE L&I | OTHER | GAB37904 | 01 | MEDICARE PROVIDER | OTHER | 650021409 | 01 | RAILROAD MEDICARE | OTHER | P01507881 | 01 | WA | RR MEDICARE | OTHER |