Provider Demographics
NPI:1205264033
Name:CONGLETON, GRADY
Entity type:Individual
Prefix:
First Name:GRADY
Middle Name:
Last Name:CONGLETON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 GOODFRIEND DR
Mailing Address - Street 2:
Mailing Address - City:EAST HAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11937-2584
Mailing Address - Country:US
Mailing Address - Phone:631-907-5000
Mailing Address - Fax:
Practice Address - Street 1:18 GOODFRIEND DR
Practice Address - Street 2:
Practice Address - City:EAST HAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11937-2584
Practice Address - Country:US
Practice Address - Phone:631-907-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-14
Last Update Date:2013-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0025832255A2300X
MA24512255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer