Provider Demographics
NPI:1568483287
Name:GRAULICH, IAN W (AT, C)
Entity Type:Individual
Prefix:MR
First Name:IAN
Middle Name:W
Last Name:GRAULICH
Suffix:
Gender:M
Credentials:AT, C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16027 PENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-1139
Mailing Address - Country:US
Mailing Address - Phone:813-977-7722
Mailing Address - Fax:
Practice Address - Street 1:13220 USF LAUREL DR, MDF 5TH FLOOR
Practice Address - Street 2:MAIL CODE MDC106
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612
Practice Address - Country:US
Practice Address - Phone:561-310-7272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 8762255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer