Provider Demographics
NPI:1679517254
Name:GRAY, JOEL THOMAS (AT/R)
Entity type:Individual
Prefix:
First Name:JOEL
Middle Name:THOMAS
Last Name:GRAY
Suffix:
Gender:M
Credentials:AT/R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8836 SW 49TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-3371
Mailing Address - Country:US
Mailing Address - Phone:503-245-1866
Mailing Address - Fax:
Practice Address - Street 1:6300 SW NICOL RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-7566
Practice Address - Country:US
Practice Address - Phone:503-416-9358
Practice Address - Fax:503-297-1105
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAT-AT-5509542255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer