=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134576945
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RORY A GRADY JR. ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2016
-----------------------------------------------------
Last Update Date | 01/13/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6600 LITTLE FALLS RD
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22213-1211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-237-1456
-----------------------------------------------------
Fax | 703-237-1465
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22575 LEANNE TER APT 444
-----------------------------------------------------
City | ASHBURN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20148-6858
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-423-1962
-----------------------------------------------------
Fax | 703-237-1465
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 002317
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------