Provider Demographics
NPI:1700368958
Name:GRADDY, KRISTEN DAWN (OTR/L)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:DAWN
Last Name:GRADDY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:DAWN
Other - Last Name:COX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:255 MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:SENOIA
Mailing Address - State:GA
Mailing Address - Zip Code:30276-3145
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1255 HIGHWAY 54 W
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4526
Practice Address - Country:US
Practice Address - Phone:229-942-8070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006152225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist