Provider Demographics
NPI:1841402708
Name:GRADY, SHAUNA S (ATC)
Entity Type:Individual
Prefix:
First Name:SHAUNA
Middle Name:S
Last Name:GRADY
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 MARINE RD
Mailing Address - Street 2:APT 2
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-0002
Mailing Address - Country:US
Mailing Address - Phone:774-722-0533
Mailing Address - Fax:
Practice Address - Street 1:84 MARINE RD
Practice Address - Street 2:APT 2
Practice Address - City:SOUTH BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02127-0002
Practice Address - Country:US
Practice Address - Phone:774-722-0533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer