Provider Demographics
NPI:1679850770
Name:GRADY, NICOLE E (PT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:E
Last Name:GRADY
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 1:20823 STEVENS CREEK BLVD
Mailing Address - Street 2:SUITE #200
Mailing Address - City:CUPERTINO
Mailing Address - State:CA
Mailing Address - Zip Code:95014-2108
Mailing Address - Country:US
Mailing Address - Phone:408-252-6076
Mailing Address - Fax:408-252-1159
Practice Address - Street 1:20823 STEVENS CREEK BLVD
Practice Address - Street 2:SUITE #200
Practice Address - City:CUPERTINO
Practice Address - State:CA
Practice Address - Zip Code:95014-2108
Practice Address - Country:US
Practice Address - Phone:408-252-6076
Practice Address - Fax:408-252-1159
Is Sole Proprietor?:No
Enumeration Date:2011-11-03
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA382362251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA38236OtherLICENSE