Provider Demographics
NPI:1457974784
Name:GRADWOHL, BRIAN DAVID (PHD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:DAVID
Last Name:GRADWOHL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1277 MERCY DR
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-4605
Mailing Address - Country:US
Mailing Address - Phone:231-672-6568
Mailing Address - Fax:
Practice Address - Street 1:1277 MERCY DR
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-4605
Practice Address - Country:US
Practice Address - Phone:231-672-6568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-21
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist