Provider Demographics
NPI:1306352810
Name:GRADY, HENRY CARROL III (COTA/L)
Entity type:Individual
Prefix:MR
First Name:HENRY
Middle Name:CARROL
Last Name:GRADY
Suffix:III
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2516 SUMMERLINS CROSSROAD RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT OLIVE
Mailing Address - State:NC
Mailing Address - Zip Code:28365-5436
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:228 SMITH CHAPEL RD
Practice Address - Street 2:
Practice Address - City:MOUNT OLIVE
Practice Address - State:NC
Practice Address - Zip Code:28365-1917
Practice Address - Country:US
Practice Address - Phone:919-658-9522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-19
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10210224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty