Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225400000X | Rehabilitation Practitioner |
NPI | 1003012675 |
---|---|
Provider Name | Michelle Irene Gray |
First Address | Waconia, MN 55387-4600 |
Second Address | Minneapolis, MN 55454-1450 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/06/2007 |
Last Update Date | 08/07/2007 |