Provider Demographics
NPI:1194116079
Name:BRADY, GINA (OTR/L)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:BRADY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:
Other - Last Name:GIBSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16290 GRIFFON TRL
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-6248
Mailing Address - Country:US
Mailing Address - Phone:507-271-0566
Mailing Address - Fax:
Practice Address - Street 1:2400 W 64TH ST
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-1001
Practice Address - Country:US
Practice Address - Phone:612-798-8323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-12
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN104748225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist