Provider Demographics
NPI:1487281804
Name:GRAY, TERESA
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2329 N FARM ROAD 197
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802-9287
Mailing Address - Country:US
Mailing Address - Phone:417-827-5444
Mailing Address - Fax:
Practice Address - Street 1:3545 S NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-7310
Practice Address - Country:US
Practice Address - Phone:417-269-5500
Practice Address - Fax:417-269-5508
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-25
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO016332251N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology