Provider Demographics
NPI:1194771345
Name:SLACK, GRADY T (DPT)
Entity type:Individual
Prefix:MR
First Name:GRADY
Middle Name:T
Last Name:SLACK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 GRANGER CIRCLE
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:NY
Mailing Address - Zip Code:14580
Mailing Address - Country:US
Mailing Address - Phone:585-787-0057
Mailing Address - Fax:
Practice Address - Street 1:1 WHIPPLE LANE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14622
Practice Address - Country:US
Practice Address - Phone:585-338-3070
Practice Address - Fax:585-336-5014
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY16909225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist