1578561817 NPI number — MRS. REBECCA A GRADY MA.

Table of content: MRS. REBECCA A GRADY MA. (NPI 1578561817)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578561817 NPI number — MRS. REBECCA A GRADY MA.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRADY
Provider First Name:
REBECCA
Provider Middle Name:
A
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MA.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BROSEKE BOWLUS
Provider Other First Name:
REBECCA
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1578561817
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/29/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
457 SW 148TH ST
Provider Second Line Business Mailing Address:
STE 101
Provider Business Mailing Address City Name:
BURIEN
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98166-1975
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-633-1810
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
457 SW 148TH ST
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
BURIEN
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98166-1975
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-246-8677
Provider Business Practice Location Address Fax Number:
206-431-2922
Provider Enumeration Date:
07/11/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 231H00000X , with the licence number:  L000001464 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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