Provider Demographics
NPI:1780172544
Name:GRADY, CODY
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:GRADY
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 1:75 CARLEE CIR S
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-8989
Mailing Address - Country:US
Mailing Address - Phone:740-348-6061
Mailing Address - Fax:
Practice Address - Street 1:3301 C ST STE 1500
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-3371
Practice Address - Country:US
Practice Address - Phone:916-734-6493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-27
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60929830225100000X
CAPT293820225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty