Provider Demographics
NPI:1649083635
Name:GRADY, JAMES COLIN (LMT)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:COLIN
Last Name:GRADY
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 204
Mailing Address - Street 2:
Mailing Address - City:SANTA
Mailing Address - State:ID
Mailing Address - Zip Code:83866-0204
Mailing Address - Country:US
Mailing Address - Phone:208-295-9500
Mailing Address - Fax:
Practice Address - Street 1:31 EAST DAVIS STREET
Practice Address - Street 2:
Practice Address - City:SANTA
Practice Address - State:ID
Practice Address - Zip Code:83866
Practice Address - Country:US
Practice Address - Phone:208-295-9500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-31
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS4960225700000X
IDMAS-4960225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist