Provider Demographics
NPI:1093110413
Name:GLYNN, GRADY (DPT)
Entity Type:Individual
Prefix:
First Name:GRADY
Middle Name:
Last Name:GLYNN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14660 LOLA AVE
Mailing Address - Street 2:
Mailing Address - City:WASECA
Mailing Address - State:MN
Mailing Address - Zip Code:56093-9002
Mailing Address - Country:US
Mailing Address - Phone:507-461-1819
Mailing Address - Fax:
Practice Address - Street 1:3050 CENTRE POINTE DR
Practice Address - Street 2:SUITE NUMBER 200
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-1102
Practice Address - Country:US
Practice Address - Phone:651-631-4242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-28
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9811225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist