Provider Demographics
NPI:1699831768
Name:HAYES, GRADY MICHAEL (OTRL)
Entity Type:Individual
Prefix:
First Name:GRADY
Middle Name:MICHAEL
Last Name:HAYES
Suffix:
Gender:M
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1079 NOTTELY DAM RD
Mailing Address - Street 2:
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30512-1798
Mailing Address - Country:US
Mailing Address - Phone:912-253-8718
Mailing Address - Fax:
Practice Address - Street 1:86 VALLEY HIDEAWAY DR
Practice Address - Street 2:
Practice Address - City:HAYESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28904-9674
Practice Address - Country:US
Practice Address - Phone:828-389-9941
Practice Address - Fax:828-389-3712
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-30
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT002619225X00000X
NC7464225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000978865Medicaid