Provider Demographics
NPI:1275659484
Name:GRADERT, BETHANY ESTELLE (MSPT)
Entity Type:Individual
Prefix:MRS
First Name:BETHANY
Middle Name:ESTELLE
Last Name:GRADERT
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 N RENGSTORFF AVE
Mailing Address - Street 2:STE A4
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94043-1750
Mailing Address - Country:US
Mailing Address - Phone:650-967-5100
Mailing Address - Fax:650-967-5101
Practice Address - Street 1:1040 N RENGSTORFF AVE
Practice Address - Street 2:STE A4
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94043-1750
Practice Address - Country:US
Practice Address - Phone:650-967-5100
Practice Address - Fax:650-967-5101
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25227225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT252270Medicare ID - Type UnspecifiedMEDICARE NUMBER