Healthcare Provider Details

I. General information

NPI: 1174029946
Provider Name (Legal Business Name): GRADY HESS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2018
Last Update Date: 04/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 BERCUT DR STE B
SACRAMENTO CA
95811-0115
US

IV. Provider business mailing address

7719 CANOVA WAY
SACRAMENTO CA
95823-4221
US

V. Phone/Fax

Practice location:
  • Phone: 916-443-2479
  • Fax:
Mailing address:
  • Phone: 916-956-1751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-16-22136
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: