Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225X00000X | Occupational Therapist | OT60020246 | WA |
Y | 225XH1200X | Occupational Therapist - Hand | OT60020246 | WA |
NPI | 1124232020 |
---|---|
Provider Name | Mr. Bradley John Gray |
First Address | Edmonds, WA 98026-8006 |
Second Address | Edmonds, WA 98026-8006 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/05/2007 |
Last Update Date | 22/12/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2033397 | (05) | WA |
332019 | WA LABOR & INDUSTRIES (01) | WA |