Provider Demographics
NPI:1649835158
Name:HARDY, GRACIE REID (LMT)
Entity type:Individual
Prefix:MRS
First Name:GRACIE
Middle Name:REID
Last Name:HARDY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MS
Other - First Name:GRACIE
Other - Middle Name:MAE
Other - Last Name:REID
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2505 POCOSHOCK PL STE 203
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23235-6356
Mailing Address - Country:US
Mailing Address - Phone:804-562-3943
Mailing Address - Fax:804-562-8136
Practice Address - Street 1:2505 POCOSHOCK PL STE 203
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23235-6356
Practice Address - Country:US
Practice Address - Phone:804-562-3943
Practice Address - Fax:804-562-8136
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-09
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019008819225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty