Provider Demographics
NPI:1003400292
Name:GRACIE, JEFFREY A
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:A
Last Name:GRACIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:348R DARK SHADE DR
Mailing Address - Street 2:
Mailing Address - City:WINDBER
Mailing Address - State:PA
Mailing Address - Zip Code:15963-6804
Mailing Address - Country:US
Mailing Address - Phone:814-691-1948
Mailing Address - Fax:
Practice Address - Street 1:348R DARK SHADE DR
Practice Address - Street 2:
Practice Address - City:WINDBER
Practice Address - State:PA
Practice Address - Zip Code:15963-6804
Practice Address - Country:US
Practice Address - Phone:814-691-1948
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-27
Last Update Date:2021-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE012721225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant