Healthcare Provider Details

I. General information

NPI: 1679850770
Provider Name (Legal Business Name): NICOLE E GRADY PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2011
Last Update Date: 11/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20823 STEVENS CREEK BLVD SUITE #200
CUPERTINO CA
95014-2108
US

IV. Provider business mailing address

20823 STEVENS CREEK BLVD SUITE #200
CUPERTINO CA
95014-2108
US

V. Phone/Fax

Practice location:
  • Phone: 408-252-6076
  • Fax: 408-252-1159
Mailing address:
  • Phone: 408-252-6076
  • Fax: 408-252-1159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number38236
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: