Provider Demographics
NPI:1063857134
Name:GRADY, REBECCA MARIE (DPT)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:MARIE
Last Name:GRADY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5533 N GALENA RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:61616-4447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5533 N GALENA RD
Practice Address - Street 2:
Practice Address - City:PEORIA HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:61616-4447
Practice Address - Country:US
Practice Address - Phone:309-682-5428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-02
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.017262225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist