Provider Demographics
NPI:1417167925
Name:GRADIN, DENISE MARIE (PT)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:MARIE
Last Name:GRADIN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 39
Mailing Address - Street 2:
Mailing Address - City:GARRISON
Mailing Address - State:ND
Mailing Address - Zip Code:58540-0039
Mailing Address - Country:US
Mailing Address - Phone:701-463-2275
Mailing Address - Fax:701-463-6569
Practice Address - Street 1:407 3 AVE SE
Practice Address - Street 2:
Practice Address - City:GARRISON
Practice Address - State:ND
Practice Address - Zip Code:58540-0039
Practice Address - Country:US
Practice Address - Phone:701-463-2275
Practice Address - Fax:701-463-6569
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND691225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND23616OtherBC BS OF ND